PrepU Ch 27 Lect.

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?

Allow the client to use the bathroom independently. Involve family members in the client's care. Maintain a high bed position so the client will not attempt to get out unassisted. Keep the client sedated with tranquilizers.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.

Drowsiness, Vomiting, Headache

A client has been diagnosed with a glioblastoma and the care team has determined that this brain tumor is inoperable. Which aspects of the client's subsequent care demonstrate adherence to the Quality and Safety Education for Nurses (QSEN) competencies? Select all that apply.

The care team meets with the client and family promptly to identify their preferences for treatment. The care team balances the best available evidence about glioblastoma treatment with the client's preferences. Each member of the care team uses the best available technology to organize and provide care. Nurses proactively identify threats to the client's safety that may occur as treatment is provided.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning? Allow the child to swim with friends. Avoid unattended baths for the toddler. Instruct the toddler not to go near the pool. Monitor the activities of the toddler.

a. Allow the child to swim with friends. b. Avoid unattended baths for the toddler. c. Instruct the toddler not to go near the pool. d. Monitor the activities of the toddler. correct: b

The nurse is admitting a client to a medical-surgical unit who states, "If someone brings balloons to me, I might have trouble breathing." What is the appropriate nursing action?

a. Keep balloons on the opposite side of the client's room. b. Replace common health care items with latex-free equipment. c. Remind the client that oranges and spinach can cause a cross-reaction. d. Assure the client that balloons do not cause breathing difficulties. correct: d

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

a. Nothing, as it is none of the nurse's concern. b. Ask to examine the client alone in order to speak to her privately. c. Report the suspicions to the authorities. d. Document the observed behaviors in the client's chart. correct: b

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

a. Pull the fire alarm lever. b. Extinguish the fire. c. Evacuate the unit. d. Confine the fire. correct: a

The nurses on a critical care unit can utilize the safety strategy of redundancy by:

a. introducing equipment that makes it more difficult for a nurse to commit an error. b. having two nurses independently check the dosage of high-risk medications. c. ensuring the antidotes are readily available for certain high-risk medications. d. introducing a brief waiting period between the time that a medication is ordered and the time that it is administered. correct: b

A nurse is performing safety assesment in a health care facility.which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply

A person with a history of falls is likely to fall again. A medication regimen that includes diuretics or analgesics places an individual at risk for falls. Some people are more at risk for accidents than others.

A nurse is educating the family caregiver of an older adult client about measures to promote client safety in the home. Which would be most appropriate to include?

a. "Make sure the client has socks on at bedtime in case of the need to use the restroom." b. "Store eyeglasses away from the bed at night to prevent breakage." c. "Use small rugs in the bathroom to keep feet warm at night." d. "Install handrails in stairways and bathrooms." correct: d

The nurse is caring for four clients. Which client does the nurse anticipate is at highest risk for latex sensitivity?

a. 44-year-old who cannot eat popcorn b. 50-year-old who reports esophageal burning when drinking grapefruit juice c. 35-year-old who has intolerance to dairy products d. 27-year-old who cannot eat avocados correct: d

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

a. A detailed description of the restraint application process b. The alternative measures attempted before applying the restraints c. The type of personal protective equipment used by the nurse during restraint application d. A verbal prescription for the restraints, renewed every 48 hours correct: b

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

a. CMS will bear the hospital's costs if the client chooses to sue the hospital. b. The hospital will be fined by CMS because the client developed a pressure injury. c. CMS may choose to divert clients to other health care facilities in the future. d. The hospital must bear any costs incurred for treating the client's injury. correct: d

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

a. Chronic Confusion Related to Long-Standing Alcohol Use b. Noncompliance Related to Medication Regimen c. Risk for Injury Related to Agitation d. Impaired Bed Mobility Related to Muscle Wasting correct: c

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

a. Educate children in cardiopulmonary resuscitation. b. Require fencing around all pools. c. Begin swim lessons with toddlers. d. Implement drowning prevention strategies. correct: d

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

a. Ensure that two fingers can be inserted between the restraint and the client's extremity. b. Apply restraints to the hands or wrists, never to the ankles. c. Use a quick-release knot to tie the restraint to the side rail. d. Remove the restraint at least every 4 hours, or according to facility policy. correct: a

The nurse has received a medication order over the telephone from a provider. What is the next appropriate nursing action?

a. Identify the client by last name and date of birth. b. Repeat or read back the order. c. Prepare the medication for administration. d. Document the order in the electronic health record (EHR). correct: b

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

a. Put up all four side rails on the bed. b. Initiate use of a bed alarm. c. Administer the client's sedative as ordered. d. Contact the physician for a restraint order.

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

a. Run the electrical cord of the pump under the carpet. b. Obtain a three-prong grounded plug adapter. c. Tape the electrical cord of the pump to the floor. d. Use an extension cord to provide freedom of movement. correct: b

When educating parents about the safety of preschool-aged children, which is most important for the nurse to include in the presentation?

a. Teach children to greet unfamiliar animals to make friends. b. Safety equipment should be used during sports activities to decrease fear. c. At home chemicals should be kept in a locked cabinet. d. Weapons should be kept in a closet to prevent access by children. correct: c

A nurse follows the universal client compact principles for partnership when providing care for clients. Which nursing action reflects this philosophy?

a. The nurse confers with members of the health care team but does not ask for family input from the assigned advocate of the client. b. The nurse does not allow the client to review his or her own medical information. c. The nurse includes the client as a member of the health care team. d. The nurse makes health care decisions for a client who is uncooperative.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

a. Using restraints on the client to prevent a fall. b. Placing the client in a bed with a bed alarm. c. Raising all the side rails of the bed. d. Providing a bed that is elevated from the floor. correct: b

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

a. articulating the reason for use of a physical restrictive device to the client's spouse. b. application of devices that reduce the client's ability to move arms. c. administration of an antipsychotic agent to alter the client's behavior. d. asking the unlicensed assistive personnel (UAP) to sit with the client. correct: c

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

a. automobile accidents. b. play-related injuries. c. falls from beds. d. falls from staircases. correct: a

The nurse is conducting a home care visit for a new mother who delivered a baby 3 days ago. Which finding within the home requires immediate nursing intervention?

a. electrical outlets with covers over them b. hot water heater thermostat set at 130 degrees F (54.4 degrees C) c. one fire extinguisher noted in the kitchen d. infant's sleepwear is made from flame-resistant fabrics correct: b

The nurse is caring for a client that was brought to the emergency department after a building fire. Which assessment finding alerts the nurse to possible smoke inhalation? Select all that apply.

black debris in nasal passages impaired judgment mild cough