Chapter 32 Safety

1. A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

1. A. By restraining the client, there is a liability risk for false imprisonment. B. Full side rails for this client puts the client at risk for a fall because they might attempt to climb over the rails to get out of bed. C. CORRECT: Making sure that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. D. CORRECT: Nonskid footwear keeps the client from slipping. E. CORRECT: A fall-risk assessment serves as the basis for a plan of care that can then individualize for the client. NCLEX® Connection: Safety and Infection Control, ,ccident0rrorInjury Prevention

1. A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.

1. A. Remind family members who smoke to do so outside. B. CORRECT: Remind the client to not use nail polish or other flammable materials in the home. C. CORRECT: Have the client place a "No Smoking" sign near the front door, and possibly on the client's bedroom door. D. Tell the client to choose cotton materials for clothing and bedding. Woolen and synthetic materials create static electricity and could cause a fire. E. CORRECT: Remind all individuals to have a fire extinguisher at home. This is especially important for a client who is receiving oxygen. NCLEX® Connection: Safety and Infection Control, Safe @se of 0\uipment

1. A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? 1. Report the fire. 2. Extinguish the fire. 3. Protect the clients. 4. Contain the fire.

1. Answer: 3. Rationale: In the event of a fire, the nurse's priority responsibility is to rescue or protect the clients under his or her care. The next priorities are to report or alert the fire department, contain or confine, and extinguish the fire. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 32-6.

10. The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply. 1. Document the behavior(s) that require continued use of the restraints. 2. Ensure that the restraints are tied to the side rails. 3. Provide range-of-motion exercises when the restraints are removed. 4. Orient the client. 5. Assess the tightness of the restraints

10. Answer: 1, 3, 4, and 5. Rationale: Standards require documentation of the necessity for restraints. The implementation of range-of-motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint. Option 2 is inappropriate because it may cause injury if the side rail is lowered without untying the restraint. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcomes: 32-9; 32-12c.

2. A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their side." B. "I will go to the nurses' station for assistance." C. "I will note the time that the seizure begins." D. "I will prepare to insert an airway."

2. A. During a seizure, place the client in a side-lying position to allow for drainage of secretions and to prevent the tongue from occluding the airway. B. CORRECT: During a seizure, stay with the client and use the call light to summon assistance. C. Note the time the seizure begins, and track how long the seizure lasts. D. Place nothing in the client's mouth except an oral airway, if necessary. A tongue blade can cause injury and airway obstruction. NCLEX® Connection: Physiological,adaptations ,alterations in Body Systems

2. A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? 1. Automobile crashes 2. Drowning and firearms 3. Falls 4. Suicide and homicide

2. Answer: 1. Rationale: When educating a group of young to middle-aged adults on safety, it is important to instruct them on the leading cause of injuries in this group. The leading cause of injuries in this group is related to automobile use. Option 2 is the leading cause for school-age children. Option 3 is the leading cause for older adults, and option 4 relates to adolescents. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 32-4.

3. A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.

3. A. Although extinguishing the fire is part of the protocol for responding to a fire, it is not the priority action. B. Although activating the fire alarm is part of the protocol for responding to a fire, it is not the priority action. C. CORRECT: The greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. Protect and move clients in close proximity to the fire. D. Although containing the fire by closing doors and windows is part of the protocol for responding to a fire, it is not the priority action. NCLEX® Connection: Safety and Infection Control, ,accident, njury Prevention

3. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicates understanding? A. "I will set my water heater at 130° F." B. "Once my baby can sit up, they should be safe in the bathtub." C. "I will place my baby on their stomach to sleep." D. "Once my infant starts to push up, I will remove the mobile from over the crib."

3. A. CORRECT: Hypotension is a manifestation of heat stroke. B. Tachycardia is a manifestation of heat stroke. C. Hot, dry skin is a manifestation of heat stroke. D. Dyspnea is a manifestation of heat stroke. NCLEX® Connection: Physiological ,daptation, Pathophysiology

3. An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? 1. Leave the bathroom light on. 2. Withhold the client's diuretic medication. 3. Provide a bedside commode. 4. Keep the side rails up.

3. Answer: 3. Rationale: The placement of the bedside commode next to his bed will assist in decreasing the number of steps he is required to ambulate. This will assist in protecting him from injury due to falls. Option 1: Leaving the light on would assist the client in locating the bathroom, but would not reduce the risk of fall when rushing to the bathroom. Option 2: The nurse cannot withhold a client's medication without consulting with the primary care provider. Option 4: If the client has orders to be up with assistance and the side rails are up, he is at risk for falls as well as falling from a greater distance. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 32-7

4. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession.

4. A. CORRECT: The first action to take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client's fall risk. This will work as a guide in implementing appropriate safety measures. B. Educate the client and family about fall risk factors so they can help promote client safety, but this is not the priority action. C. Eliminate safety hazards from the client's environment to help reduce the risk for falls, but this is not the priority action. D. Aids (eyeglasses, hearing aids, canes, and walkers) should be accessible to reduce the client's risk for falls, but this is not the priority action. NCLEX® Connection: Safety and Infection Control, ,ccident0rrorInjury Prevention

4. A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include? A. Carbon monoxide has a distinct odor. B. Water heaters should be inspected every 5 years. C. The lungs are damaged from carbon monoxide inhalation. D. Carbon monoxide binds with hemoglobin in the body.

4. A. Include that carbon monoxide cannot be seen, smelled, or tasted. B. Tell the client to inspect gas-burning furnaces, water heaters, and appliances annually. C. Inform the client that carbon monoxide impairs the body's ability to use oxygen, but the lungs are not damaged. D. CORRECT: Warn the client that carbon monoxide is very dangerous because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body. NCLEX® Connection: Safety and Infection Control, Home Safety

4. A mother and her 3-year-old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child? 1. Risk for Suffocation 2. Risk for Injury 3. Risk for Poisoning 4. Risk for Disuse Syndrome

4. Answer: 3. Rationale: A home that was built prior to 1978 has leadbased paint. The ingestion of lead-based paint chips places that child at risk for elevated serum lead levels and neurologic deficits. The most appropriate nursing diagnosis for this child is Risk for Poisoning. Option 1: The risk for suffocation is greater in infants and is not related to a home with lead-based paint. Options 2 and 4 are not related to lead-based paint. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Nursing Diagnosis. Learning Outcome: 32-5.

5. A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A. Open the windows in the client's room to allow smoke to escape. B. Obtain a class C fire extinguisher to extinguish the fire. C. Remove all electrical equipment from the client's room. D. Place wet towels along the base of the door to the client's room.

5. A. Close all doors and windows to contain the fire. B. Attempt to extinguish the fire with a class A fire extinguisher, which is used for ordinary combustibles (cloth and paper). C. Removing all the electrical equipment is not needed, but do turn off all the electrical equipment in the client's room. D. CORRECT: Place wet towels along the base of the door to the client's room to contain the fire and smoke in the room. NCLEX® Connection: Reduction of Risk Potential, System Speciʭc ,ssessments

5. A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include? (Select all that apply.) A. Most food poisoning is caused by a virus. B. Immunocompromised individuals are at increased risk for complications from food poisoning. C. Clients who are at high risk should eat or drink only pasteurized dairy products. D. Healthy individuals usually recover from the illness in a few weeks. E. Handling raw and fresh food separately can prevent food poisoning

5. A. Include that most food poisoning is caused by bacteria (Escherichia coli, Listeria monocytogenes, and Salmonella). B. CORRECT: Warn the client that very young, very old, immunocompromised, and pregnant individuals are at increased risk for complications from food poisoning. C. CORRECT: Include that clients who are at high risk should follow a low-microbial diet, which includes eating or drinking only pasteurized milk, yogurt, cheese, and other dairy products. D. Inform the client that healthy individuals usually recover from the illness in a few days. E. CORRECT: Include interventions to prevent food poisoning (performing proper hand hygiene, cooking meat and fish to the correct temperature, handling raw and fresh food separately to avoid cross-contamination, and refrigerating perishable items). NCLEX® Connection: Physiological ,daptation, Pathophysiology

5. A 75-year-old client, hospitalized with a cerebrovascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure? 1. Restrain the client in bed. 2. Ask a family member to stay with the client. 3. Check the client every 15 minutes. 4. Use a bed exit safety monitoring device.

5. Answer: 4. Rationale: Option 4 is an intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety. Option 1 can increase agitation and confusion and removes the client's independence. Option 2 would help but transfers the responsibility to the family member. Option 3 is inappropriate since the client could fall during the unobserved interval and it is not a realistic answer for the nurse. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcomes: 32-6; 32-12a.

6. A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? Select all that apply. 1. Place a padded tongue depressor at the head of the bed. 2. Pad the bed with blankets. 3. Inform the client about the importance of wearing a medical identification tag. 4. Teach the client about epilepsy. 5. Test oral suction equipment.

6. Answer: 2 and 5. Rationale: Options 2 and 5 are measures needed to keep the client safe in the event of another seizure. Option 1 is incorrect because the current nursing literature states to not put anything in the client's mouth during a seizure. Options 3 and 4 are more relevant after the cause of the seizure is known. Seizures are not all classified as epilepsy. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcomes: 32-8; 32-12b.

7. Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting? 1. Keep all of the side rails up. 2. Review prescribed medications. 3. Complete the "get up and go" test. 4. Place the bed in the lowest position.

7. Answer: 4. Rationale: Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting out of a bed that is at an appropriate height. Option 1 can cause a fall with injury because the client may fall from a higher distance when trying to get over the rail. Option 2 is important to do as certain medications can increase the risk of falling; however, this is not the best answer because it is not applicable to all clients. Option 3 would help the nurse to assess a client's risk for falling but would not prevent injury. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome

8. Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply. 1. Hire only competent nurses. 2. Improve the nurse's ability to multitask. 3. Establish a reporting system for "near misses." 4. Communicate effectively. 5. Create a culture of trust.

8. Answer: 3, 4, and 5. Rationale: Reviewing near misses could identify flaws in the system or practices that placed the client at risk. Communication among staff and with clients will increase the efficiency and create an atmosphere where nurses are willing to discuss errors openly so that the flaws in the system can be corrected. Options 1 and 2 are inappropriate answers. A competent nurse may make medication errors. Also, evidence is needed to support these conclusions. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcomes: 32-1; 32-3.

9. When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority? 1. Sports contribute to an adolescent's self-esteem. 2. Sunbathing and tanning beds can be dangerous. 3. Guns are the most frequently used weapon for adolescent suicide. 4. A driver's education course is mandatory for safety.

9. Answer: 3. Rationale: Suicide and homicide are two leading causes of death among teenagers. Adolescent males commit suicide at a higher rate than adolescent females. Options 1 and 2 are true; however, neither would be as high a priority as preventing suicide. Option 4 is not true. A driver's education course does not ensure safe practice. Cognitive Level: Analysis. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 32-4.

2. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

2. A. CORRECT: Hypotension is a manifestation of heat stroke. B. Tachycardia is a manifestation of heat stroke. C. Hot, dry skin is a manifestation of heat stroke. D. Dyspnea is a manifestation of heat stroke. NCLEX® Connection: Physiological ,daptation, Pathophysiology