EAQ - Ch. 27 - Safety & Nursing Process
A registered nurse (RN) is teaching a patient about preventive measures for electrical shocks. Which statement by the patient indicates the need for further teaching? 1 "I will use extension cords at all times." 2 "I will not operate unfamiliar equipment." 3 "I will keep the electrical items away from water." 4 "I will grasp the plug, not the cord, while unplugging."
1 "I will use extension cords at all times."
In a health care setting, the restraint order for a patient is renewed every hour. What is the likely age of the patient? 1 6 years 2 14 years 3 23 years 4 65 years
1 6 years In a hospital setting, each original restraint order and renewal is limited to 8hours for adults, 2hours for children ages 9 to 17, and one hour for children under the age of 9. Therefore, a restraint order for a 6-year-old child will require renewal every hour. A restraint order for a 14-year-old patient will require renewal every 2 hours. Restraint orders for the 23-year-old and 65-year-old patients will require renewal every 8 hours.
A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. What should the nurse consider when providing discharge teaching about home safety to this patient and her husband? 1 A safe environment promotes patient activity. 2 Assessment focuses on environmental factors only. 3 Teaching home safety is difficult to do in the hospital setting. 4 Most accidents with the older adult are caused by lifestyle factors
1 A safe environment promotes patient activity. Older adults are frequently fearful of falling and thus often limit activity. A safe environment, which decreases the risk of a fall, promotes patient activity.
A patient is having left-sided weakness due to a cerebrovascular accident. The nurse observes that the patient is having difficulty focusing during the conversation. Which nursing intervention will be beneficial in this situation? 1 Encouraging the patient to use effective coping skills he or she has previously used 2 Teaching the patient about the use of a walker and cane around the home Incorrect3 Consulting with a physical therapist to help the patient with strengthening exercises 4 Encouraging the family to eat with the patient and remind him or her to eat food on the left side of plate
1 Encouraging the patient to use effective coping skills he or she has previously used A patient who has anxiety related to fear of falling may have difficulty focusing during conversation. The appropriate intervention in this situation is to encourage the patient to use the effective coping skills he or she has previously used. Teaching the patient about the use of a walker and cane around the home is an intervention for impaired physical mobility. Consulting with a physical therapist to help the patient with strengthening exercises will be beneficial for a patient who is at risk for falls. Encouraging the family to eat with the patient and reminding him or her to eat food on the left side of the plate will be beneficial for a patient with unilateral neglect of the brain due to injury related to cerebrovascular accident.
Which care intervention would reduce the risk of sudden infant death syndrome (SIDS)? 1 Immunizing the infant 2 Using snug-fitting sheets 3 Using large soft toys without small hard pieces 4 Avoiding leaving the baby unattended on the changing table
1 Immunizing the infant Immunizing the infant will reduce the risk of SIDS. The use of a snug-fitting sheet would prevent suffocation, strangulation, or entrapment. Small parts of toys may become dislodged and the infant may choke on them; therefore, the use of large, soft toys without small parts, such as buttons, would prevent choking and aspiration. Not leaving an infant unattended on the changing table prevents falls, not SIDS.
Which restraint is banned due to the risk of fatal injuries? 1 Jacket restraint 2 Elbow restraint 3 Mitten restraint 4 Extremity restraint
1 Jacket restraint Jacket restraint is banned due to the risk of fatal injuries. Elbow restraint is used commonly with infants and children to prevent elbow flexion. Mitten restraint prevents patients from dislodging invasion equipment. Extremity restraint is designed to immobilize one or all extremities.
The registered nurse is teaching a group of student nurses about various problems faced by older adults and effective interventions to overcome those problems. Which patient information provided by the registered nurse needs correction? 1 Patient 1 2 Patient 2 3 Patient 3 4 Patient 4
1 Patient 1 Nocturia and incontinence are common problems in older adults. Interventions include instituting a regular toileting schedule with a recommended frequency of every 3 hours. Giving diuretics in the morning will also be beneficial in these patients. The nurse should provide adequate and meaningful stimuli when an older adult shows a reduced response to multiple stimuli. Older adults should be encouraged to engage in physical activity to increase their range of motion and strength. An older adult who has diminished memory may not take medications correctly. The nurse should encourage the use of medication organizers. Older adults are at a high risk for automobile accidents due to slowed reaction time. Therefore, the nurse should teach safety tips for avoiding automobile accidents.
An 80-year-old patient demonstrates some confusion but no anxiety. The nursing assessment reveals that the patient is a fall risk because the patient continues to get out of bed without help despite frequent reminders. Which nursing intervention should be initiated to prevent falls for this patient? 1 Place a bed alarm device on the bed. 2 Place the patient in a belt restraint. 3 Provide one-on-one observation of the patient. 4 Apply wrist restraints.
1 Place a bed alarm device on the bed. The nurse should consider and implement alternatives as appropriate before using a restraint. A bed alarm is an alternative that the nurse implements independently.
At 3 AM the emergency department nurse hears that a tornado hit the east side of town. Which action should the nurse take first? 1 Prepare for an influx of patients. 2 Contact the American Red Cross. 3 Determine how to restore essential services. 4 Evacuate patients per the disaster plan
1 Prepare for an influx of patients. The emergency department nurse first needs to prepare for the potential influx of patients. Staff should be aware of the disaster plan. Patients may need to be evacuated but not initially. The American Red Cross is not contacted initially. Determination of how to restore essential services is part of the disaster plan and is determined before an actual event.
An elderly patient who is on medications for hypertension and diabetes mellitus frequently skips doses due to diminishing memory. How can the nurse help this patient improve medication compliance? 1 Promote the use of a medication organizer. 2 Reward the patient to promote compliance. 3 Explain the side effects of the medications. 4 Convince the patient of the need to adhere to treatment
1 Promote the use of a medication organizer. Medication organizers and pillboxes are cost-effective dispensers that help to dispense medications appropriately. Rewarding and punishing are not ideal methods of training an elderly patient with compromised memory to take medications consistently. Informing the patient about the side effects of medications would not be helpful in improving medication compliance, because the patient may already be perfectly informed of the medication but still unable to remember to take it. Convincing the patient of the importance of adhering to treatment would be appropriate for patients with normal cognitive functioning, but this approach is not suitable for patients with a memory disturbance.
A patient reports difficulty seeing objects at a distance after a cerebrovascular accident. What would the nurse anticipate? 1 Risk of falls 2 Anxiety related to fear of falling 3 Unilateral neglect due to brain injury 4 Impaired physical mobility on one side of the body
1 Risk of falls The nursing diagnosis for a patient who experiences a cerebrovascular accident and reports difficulty seeing objects at a distance will be at elevated risk of falls. If a patient is worried about falling and health status, the nurse may identify anxiety related to fear of falling. If the nurse finds that the patient does not eat food on one side of the plate, it may indicate unilateral neglect due to brain injury. If a patient has difficulty performing fine and gross motor skills on one side of the body, it indicates impaired physical mobility on one side of the body.
A patient who was admitted to the hospital receives a red-color wristband for identification purposes. What is the significance of the wristband? 1 The patient has allergies. 2 The patient is at risk for falling. 3 The patient should be treated immediately. 4 The patient is not indicated for resuscitation
1 The patient has allergies. The American Hospital Association issued an advisory recommendation that hospitals use standardized wristband colors. Red wristbands indicate patient allergies. Yellow wristbands are for patients who are at a risk for falling. There is no wristband for immediate treatment of patients. Purple wristbands are given to patients who have do-not-resuscitate orders.
Which restraint should the nurse use to prevent nerve injury? 1 Belt 2 Elbow 3 Mitten 4 Extremity
2 Elbow Elbow restraint, or the freedom splint, is commonly used with infants and children to prevent elbow flexion. This helps keep the elbow extended and prevents nerve injury in cases where the IV line is placed in the antecubital fossa. Belt restraint is used to maintain the center of gravity and prevents patients from rolling off stretchers or sitting up while on stretchers, as well as from falling out of bed. Mitten restraints prevent patients from dislodging invasive equipment, removing dressings, or scratching. Extremity restraints maintain immobilization of extremities to protect patients from falling or accidental removal of therapeutic devices.
Which recommendation would be appropriate to reduce the risk of falls in a patient with hemiparesis? 1 "You should perform range-of-motion exercises." 2 "You should make use of coping skills that you have previously used." 3 "You should consult an ophthalmologist for a visual assessment." 4 "You should touch one side of your body frequently with the other hand.
3 "You should consult an ophthalmologist for a visual assessment." Hemiparesis is the condition in which there is weakness on one side of the body. Consulting an ophthalmologist for visual assessment will prevent the risk of fall in a hemiparesis patient. Performing range-of-motion exercises will be helpful for a patient with impaired physical mobility. Encouraging the patient to make use of coping skills that he or she has previously used is helpful for a patient with anxiety related to falls. A patient with unilateral neglect related to brain injury will benefit from frequently touching the left side of the body with the right hand.
A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which is the most important instruction the nurse should give to this parent? 1 Give the child milk. 2 Give the child syrup of ipecac. 3 Call the Poison Control Center. 4 Take the child to the emergency department.
3 Call the Poison Control Center.
Which intervention would the nurse employ to reduce the risk of falling in the health care setting due to tripping? 1 Cleaning all spills promptly 2 Ensuring adequate glare-free lighting 3 Keeping the floor free of clutter and obstacles 4 Having assistive devices on the exit side of the bed
3 Keeping the floor free of clutter and obstacles Falls in the health care setting have many etiologies. The nurse keeps the floor free of clutter and obstacles to reduce the risk of falling due to tripping, especially in an unfamiliar setting. The nurse cleans all spills promptly to reduce the risk of falling due to slipping on wet surfaces. The nurse ensures adequate, glare-free lighting to reduce the risk of falling due to visual decline or disturbances. The nurse keeps assistive devices on the exit side of the bed to reduce the risk of falling due to decreased mobility status.
Which should the nurse do first after discovering an electrical fire in a patient's room? 1 Activate the fire alarm. 2 Confine the fire by closing all doors and windows. 3 Remove all patients in immediate danger. 4 Extinguish the fire by using the nearest fire extinguisher
3 Remove all patients in immediate danger. Follow the acronym RACE. The first step is to Rescue and Remove all patients in immediate danger.
A patient has been having seizures for more than 30 minutes. The nurse looks after the patient and implements the best efforts to keep the patient safe. Which nursing intervention may lead to complications in the patient? 1 Calling a rapid response team 2 Notifying a health care provider 3 Restraining the patient to prevent injuries 4 Maintaining the airway and administering oxygen Seizures persisting beyond 30 minutes indicate status epilepticus, which is a medical emergency. Restraining the patient further aggravates the injuries during an active episode and should be avoided. Status epilepticus is managed by calling a rapid response team or code blue and notifying a health care provider. The nurse should also take the necessary steps to maintain the airway. If oxygen saturation has dropped to a critical level, then oxygen should be administered.
3 Restraining the patient to prevent injuries Seizures persisting beyond 30 minutes indicate status epilepticus, which is a medical emergency. Restraining the patient further aggravates the injuries during an active episode and should be avoided. Status epilepticus is managed by calling a rapid response team or code blue and notifying a health care provider. The nurse should also take the necessary steps to maintain the airway. If oxygen saturation has dropped to a critical level, then oxygen should be administered.
While caring for a patient with left-sided weakness, the nurse suspects impaired physical mobility. Which clinical manifestation would further confirm the nurse's suspicion? 1 The patient has difficulty seeing objects at a distance. 2 The patient is concerned about the potential risk of fall and injury. 3 The patient has limited ability to perform fine and gross motor skills on left side. 4 The patient does not move the head to the left side in response to loud noises on the left side
3 The patient has limited ability to perform fine and gross motor skills on left side. A patient's exhibiting limited ability to perform fine and gross motor skills on the left side indicates impaired physical mobility related to left-sided weakness. Difficulty seeing objects at a distance indicates that a patient is at a risk for falls. When a patient is worried about falling and injury, it indicates anxiety related to fear of falling. Lack of responsiveness to loud noise on the left side indicates unilateral neglect related to brain injury.
The registered nurse (RN) is teaching a nursing student about approaches to teaching a patient the proper use of a fire extinguisher at home. Which statement by the nursing student indicates a need for further teaching? 1 "I should instruct the patient to memorize the mnemonic PASS." 2 "I should explain how to choose the location for extinguishers." 3 "I should describe the steps to be taken before the extinguisher is used." 4 "I should teach the patient to attempt to control the fire before calling emergency services."
4 "I should teach the patient to attempt to control the fire before calling emergency services." The nurse should teach the patient to attempt to fight the fire only after calling emergency services. The nurse should instruct the patient to memorize the mnemonic PASS. The nurse should teach the patient to place an extinguisher in the kitchen, near the furnace, and in the garage. The nurse should teach the patient the steps to take before using the extinguisher.
Which suggestion would be appropriate to prevent unilateral neglect in a patient with hemiparesis? 1 "You should perform range-of-motion exercises." 2 "You should use a walker and cane around the home." 3 "You should consult with an ophthalmologist for visual assessment." 4 "You should touch one side of the body frequently with the other hand."
4 "You should touch one side of the body frequently with the other hand." Hemiparesis is a condition in which there is weakness on one side of the body. A patient with unilateral neglect related to brain injury will benefit from touching the left side of the body frequently with the right hand. Performing range-of-motion exercises is helpful for patients with impaired physical mobility. Using a walker or cane around the home is helpful for patients with impaired physical mobility. Consulting an ophthalmologist for visual assessment will help prevent the risk of falls in a patient with hemiparesis
A couple intends to take their 5-year-old child for a long ride in a car. What advice should the nurse provide to this couple? 1 Advise the couple that the child can ride in the front seat for short rides, but not long rides. 2 Discourage taking the child for a long ride, because this may disrupt the child's usual routine. 3 Advise the couple to leave the child unbuckled but sitting on an adult's lap if a car seat is unavailable. 4 Advise the couple of the need for an appropriate car seat for this child
4 Advise the couple of the need for an appropriate car seat for this child Children less than 8 years of age or those who weigh less than 80 pounds should use an appropriate car seat as specified by the manufacturer. If there is a car accident, the child is likely to have fewer injuries when seated in the back seat than the front seat, regardless of the length of the drive. It is inappropriate to advise the parents to avoid taking children for long rides. Children should be taken for family rides with appropriate safety measures. In cases of a sudden stop or a car crash, the child is susceptible to severe head injuries if left unrestrained; therefore, a child should never sit on an adult's lap rather than being properly buckled into a car seat.
A child in the hospital starts to have a grand mal seizure while playing in the playroom. Which is the most important nursing intervention during this situation? 1 Begin cardiopulmonary respiration. 2 Restrain the child to prevent injury. 3 Place a tongue blade over the tongue to prevent aspiration. 4 Clear the area around the child to protect the child from injury.
4 Clear the area around the child to protect the child from injury. Once a seizure begins, the nurse needs to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth.
There is a fire in a hospital. Which is the priority action of the nurse? 1 Activating the fire alarms 2 Confining the fire 3 Extinguishing the fire 4 Rescuing patients in immediate danger
4 Rescuing patients in immediate danger The nurse should use the mnemonic RACE to set priorities in case of a fire. When there is a fire in a hospital, the nurse's first and most important intervention is to Rescue and remove all patients who are in immediate danger. After those patients are removed, the nurse should Activate the fire alarm so that other patients and staff will know of the fire danger. After this the nurse should Confine the fire by closing all doors and windows and turning off oxygen and electrical equipment. Finally, the nurse may attempt to Extinguish the fire with the use of an appropriate fire extinguisher.
