Fundamental Success: Safety

32. Which human response to illness alerts the nurse that a patient has the greatest risk for aspiration during meals? 1. Bulimia 2. Lethargy 3. Anorexia 4. Stomatitis

2 When a person is sleepy, sluggish, or stuporous (lethargic), there may be a reduced level of consciousness and diminished reflexes, including the gag and swallowing reflexes. This condition can result in aspiration of food or fluids that can compromise the person's airway and respiratory status. An inflammation of the mucous membranes of the mouth (stomatitis) may result in dysphagia and increase the risk of aspiration but dysphagia is not an option.

13. A patient with Parkinson's disease is experiencing difficulty swallowing. The nurse understands that the most serious risk associated with dysphagia is: 1. Anorexia 2. Aspiration 3. Self-care deficit 4. Inadequate intake

2 When a person has difficulty with swallowing (dysphagia), food or fluid can pass into the trachea and be inhaled into the lungs (aspiration) rather than swallowed down the esophagus. This can result in choking, partial or total airway obstruction, or aspiration pneumonia. 1 and 4 are less serious risks.

28. The nurse is planning care for a patient who requires bilateral arm restraints. Which information is important to understand when planning care for this patient? 1. Their use adequately prevents injuries 2. They require a physician's order to be applied 3. Reasons for their use must be clearly documented 4. Most patients recognize that they contribute to their safety

3 All patient care, including the use of restraints, should adhere to standards of care. The reason for the use of restraints must adhere to standards of care and be documented on the patient's hospital record to create a legal record that protects the patient as well as the health- care providers.

20. The nurse understands that the most common factor that contributes to falls in the hospital setting is: 1. Wet floors 2. Frequent seizures 3. Advanced age of patients 4. Misuse of equipment by nurses

3 Older adults who are hospitalized frequently have multiple health problems, are frail, and lack stamina. All of these contribute to the inability to maintain balance and ambulate safely. 1, 2, and 4 are uncommon.

29. The nurse understands that injuries in hospitalized patients are caused most commonly by: 1. Malfunctioning equipment 2. Failure to use restraints 3. Visitors 4. Falls

4 Research demonstrates that most injuries experienced by hospitalized patients occur from falls. Failing to call for assistance, inadequate lighting, and the physical condition of the patient all contribute to falls.

21. An adaptation that indicates that a further nursing assessment is necessary to determine if the patient has difficulty swallowing is: 1. Abdominal cramping 2. Epigastric pain 3. Constipation 4. Drooling

4 The body continuously secretes saliva (approximately 1000 mL a day) that usually is swallowed. When saliva accumulates and is not swallowed, it dribbles out of the mouth (drooling). This indicates the need to assess swallowing ability.

25. The nurse is caring for a patient with a nasogastric tube for gastric decompression. Which nursing action takes priority? 1. Positioning the patient in the semi-Fowler's position 2. Instilling the tube with 30 mL of air every 2 hours 3. Providing care to the nares at least every 8 hours 4. Discontinuing wall suction when providing care

1 A nasogastric (NG) tube for gastric decompression passes down the esophagus, through the cardiac sphincter, and into the stomach. The cardiac sphincter remains slightly open because of the presence of the NG tube. The semi-Fowler's position keeps gastric secretions in the stomach via gravity (preventing reflux and aspiration) and allows the gastric contents to be suctioned out by the NG tube. 2 only needs to happen to identify the tube's presence in the stomach. 3 should happen more frequently to avoid irritation.

33. The nurse is preparing a patient for a physical examination. In this situation it is most important for the nurse to: 1. Identify positions that may be contraindicated for the patient during the examination 2. Explore the patient's attitude toward health-care providers 3. Inquire about the other professionals caring for the patient 4. Ask when the patient last had a physical examination

1 A physical examination requires a patient to assume a variety of positions such as supine, side-lying, sitting, and standing. The nurse should inquire about any positions that are uncomfortable or contraindicated because of past or current medical conditions to prevent complications.

12. The nurse understands that in the hospital setting an electrical appliance should have a three-pronged plug because it: 1. Controls stray electrical currents 2. Promotes efficient use of electricity 3. Shuts off the appliance if there is an electrical surge 4. Divides the electricity among the appliances in the room

1 A three-pronged plug functions as a ground to dissipate stray electrical currents.

9. Which is the first action the home care nurse should employ to prevent falls by an older adult living at home? 1. Conduct a comprehensive risk assessment 2. Encourage the patient to remove throw rugs in the home 3. Suggest installation of adequate lighting throughout the home 4. Discuss with the patient the expected changes of aging that place one at risk

1 Assessment is the first step of the Nursing Process. The best way to prevent falls is by instituting extra fall precautions for those patients at the highest risk. Most agencies have policies and procedures designed to identify, monitor, and support patients at risk. 2,3, and 4 are advisable but not priorities.

5. The nurse is orienting a newly admitted patient to the hospital. It is most important for the nurse to teach the patient how to: 1. Notify the nurse when help is needed 2. Get out of the bed to use the bathroom 3. Raise and lower the head and foot of the bed 4. Use the telephone system to call family members

1 Explaining how to use a call bell meets safety and security needs. It reinforces that help is immediately available at a time when the patient may feel physically or emotionally vulnerable in an unfamiliar environment.

7. The nurse must apply a hospital gown to a patient receiving an intravenous infusion in the forearm. The nurse should: 1. Insert the IV bag and tubing through the sleeve from inside of the gown first 2. Disconnect the IV at the insertion site, apply the gown, and then reconnect the IV 3. Close the clamp on the IV tubing no more than 15 seconds while putting on the gown 4. Don the gown on the arm without the IV, drape the gown over the other shoulder, and adjust the closure behind the neck

1 This ensures that the IV bag and tubing are safely passed through the armhole of the gown before the patient puts the arm with the insertion site through the gown. This prevents tension on the tubing and insertion site, which limits the possibility of the catheter dislodging from the vein. 2 and 3 are unsafe.

31. Which nursing intervention enhances an older adult's sensory perception and thereby helps prevent injury when walking from the bed to the bathroom? 1. Providing adequate lighting 2. Raising the pitch of the voice 3. Holding onto the patient's arm 4. Removing environmental hazards

1 This provides for the safety of patients, staff, and visitors within a hospital. Inadequate lighting causes shadows, a dark environment, and the potential for misinterpreting stimuli (illusions), and is a major cause of accidents in the hospital setting.

Which actions are important when the nurse uses a stretcher? Check all that apply. 1. _____ Lowering the bed below the level of the stretcher when transferring a patient from the stretcher to a bed 2. _____ Guiding the stretcher around a turn leading with the end with the patient's head 3. _____ Ensuring the patient's head is at the end with the swivel wheels 4. _____ Pulling the stretcher on the elevator with the patient's feet first 5. _____ Pushing the stretcher from the end with the patient's head

1 & 5 1. Keeping a bed lower than a stretcher when transferring a patient from the stretcher to a bed utilizes gravity which places less stress and strain on both the patient and nurses. 5. The swivel wheels must be under the patient's feet on the leading end of the stretcher for safe maneuverability. A stretcher should always be pushed, not pulled, so that the transporter stays at the patient's head for protection. The pt should be moved into an elevator head first, not feet first. Turning the end with the pt's head is dangerous because it can cause dizziness.

19. A toaster is on fire in the pantry of a hospital unit. The nurse should first: 1. Unplug the toaster 2. Activate the fire alarm 3. Put out the fire with an extinguisher 4. Evacuate patients from the room next to the kitchen

2 Because no patient is in jeopardy, the nurse's initial action should be to activate the alarm. The sooner the alarm is set, the sooner professional firefighters will reach the scene of the fire.

The nurse teaches a nursing assistant that the last step in making an occupied bed is: 1. Raising both side rails on the bed 2. Lowering the height of the bed toward the floor 3. Ensuring that the patient is in a comfortable position 4. Elevating the head of the bed to a semi-Fowler's position

2 It is safer if the bed is in the lowest position and the patient's feet are flat on the floor when getting in or out of bed. A greater risk for injury to a patient occurs when the mattress of the bed is further from the floor.

10. The nurse is preparing a bed to receive a newly admitted patient. Which action is most important? 1. Place the patient's name on the end of the bed 2. Ensure that the bed wheels are locked 3. Position the call bell in reach 4. Make an open bed

2 Locked bed wheels are an important safety precaution. The bed must be an immovable object because the patient may touch the bed for support, lean against it when getting in or out of bed, or move around when in bed. If the bed wheels are unlocked during these maneuvers, the bed may move and the patient can fall. 3 will follow after and 4 is optional.

30. When caring for patients, which is the first thing the nurse should do to prevent problems associated with latex allergies? 1. Use nonlatex gloves 2. Identify persons at risk 3. Keep a latex-safe supply cart available 4. Administer an antihistamine prophylactically

2 Patient allergies must be identified (e.g., latex, food, medication, etc.) before any care is provided, documented in the patient's hospital record, and appear on an allergy-alert wristband. After a risk is identified, additional safety precautions can be implemented to prevent exposure to the offending allergen. Assessment is the first step of the Nursing Process.

6. Profuse smoke is coming out of the heating unit in a patient's room. The nurse should first: 1. Open the window 2. Activate the fire alarm 3. Move the patient out of the room 4. Close the door to the patient's room

2 The patient's physical safety is the priority. The patient must be removed from direct danger before the alarm is activated and the fire contained. 2 and 4 will follow after.

17. An unconscious patient begins vomiting. In which position should the nurse place the patient? 1. Supine 2. Side-lying 3. Orthopneic 4. Low-Fowler's

2 The side-lying position prevents the tongue from falling to the back of the oropharynx, allowing the vomitus to flow out of the mouth by gravity and thus preventing aspiration. Supine and low-fowler's will promote aspiration. Orthopneic is impossible to maintain an unconscious pt.

18. The nurse is assisting a patient to use a bedpan. What is the most important nursing intervention? 1. Dusting powder on the rim before placing the bedpan under the patient 2. Positioning the rounded rim of the bedpan toward the front of the patient 3. Ensuring that the bedside rails are raised once the patient is on the bedpan 4. Encouraging the patient to help as much as possible when using the bedpan

3 Patient safety is a priority. A bedpan is not a stable base of support and the effort of elimination may require movements that alter balance. Side rails provide a solid object to hold while balancing on the bedpan and supply a barrier to prevent falling out of bed.

8. The nurse is planning care for a patient with a wrist restraint. The restraint should be removed, the area massaged, and the joints moved through their full range every: 1. Shift 2. Hour 3. Two hours 4. Four hours

3 Restraints should be removed every 2 hours. The extremities must be moved through their full range of motion to prevent muscle shortening and contractures. The area must be massaged to promote circulation and prevent pressure injuries. If kept on for too long, restraints cause contractures.

23. To best prevent a patient from falling, the nurse should: 1. Provide a cane 2. Keep walkways clear of obstacles 3. Assist the patient with ambulation 4. Encourage the patient to use the handrails in the hall

3 This widens the patient's base of support, which improves balance and decreases the risk of a fall. 2 and 4 can follow after.

22. The nurse is assessing a patient who is being admitted to the hospital. Which is the most important information collected by the nurse that indicates whether the patient is at risk for physical injury? 1. Weakness experienced during a prior admission 2. Medication that increases intestinal motility 3. Two recent falls that occurred at home 4. The need for corrective eyeglasses

3 This is significant information that must be considered because if falls occurred before, they are likely to occur again. When a risk is identified, additional injury prevention precautions can be implemented.

34. The nurse identifies the presence of a fire in the dirty utility room. Place the nurse's actions in order of priority. 1. Pull the fire alarm 2. Close unit doors and windows 3. Shut the door to the utility room 4. Provide emotional support to agitated patients

3 1 2 4 3. Closing the door to the dirty utility room protects the patients and staff members in the immediate vicinity of the fire. 1. Pulling the fire alarm ensures that appropriate hospital personnel and the fire department are notified of the fire. Trained individuals will arrive to contain and extinguish the fire and help move patients if necessary. 2. Closing unit doors and windows provide a barrier between the patients and the fire and limit drafts that could exacerbate the fire. 4. Patients should be supported emotionally during a crisis because anxiety can be contagious.

27. The nurse identifies that the hospitalized patient at the greatest risk for injury is a: 1. Young child 2. Comatose teenager 3. Postmenopausal woman 4. Confused middle-aged man

4 A confused patient is at an increased risk for injury because of the inability to comprehend cause and effect and, therefore, lacks the ability to make safe decisions

4. A patient consistently tries to pull out a urinary retention catheter. As a last resort to maintain integrity of the catheter and patient safety, the nurse obtains an order for a restraint. Which type of restraint is most appropriate in this situation? 1. Mummy restraint 2. Elbow restraint 3. Jacket restraint 4. Mitt restraint

4 A mitt restraint covers the hand to prevent the fingers from grasping and pulling out tubes. A jacket restraint usually is used to keep a person from falling out of bed while not immobilizing the extremities. Mummy and elbow restraints are usually used for infants and children.

3. Which time of day is of most concern for the nurse when trying to protect a patient with dementia from injury? 1. Afternoon 2. Morning 3. Evening 4. Night

4 At night, patients with dementia often continue to experience confusion and agitation. At night there is less light, less activity, and fewer caregivers, so there are fewer orienting stimuli. Patients who are confused or agitated are at an increased risk for injury because they may not comprehend cause and effect and, therefore, lack the ability to make safe judgments.

14. The nurse is caring for a confused patient. To prevent this patient from falling, the nurse should: 1. Encourage the patient to use the corridor handrails 2. Place the patient in a room near the nurses' station 3. Reinforce how to use the call bell 4. Maintain close supervision

4 Maintaining safety of the confused patient is best accomplished through close or direct supervision. Confused patients cannot be left on their own because they may not have the cognitive ability to understand cause and effect, and therefore their actions can result in harm.

1. A patient has dysphagia. Which common nursing action takes priority when feeding this patient? 1. Ensuring that dentures are in place 2. Medicating for pain before providing meals 3. Providing verbal cueing to swallow each bite 4. Checking the mouth for emptying between every bite

4 This is the safest way to ensure that a bolus of food is not left in the mouth where it can be aspirated and cause an airway obstruction.

11. An appropriately worded goal associated with the nursing diagnosis Risk for Injury is, "The patient will be: 1. Taught how to call for help to ambulate." 2. Kept on bed rest when dizzy." 3. Restrained when agitated." 4. Free from trauma."

4 This is an appropriate goal. It is realistic, specific, measurable, and has a time frame. It is realistic to expect that all patients be safe. It is specific and measurable because safety from trauma can be compared to standards of care within the profession of nursing. It has a time frame because the words free from reflect the time frames of always, constantly, and continuously. 1, 2, and 3 are interventions.