prepU: Safety questions
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? Obtain a three-prong grounded plug adapter. Use an extension cord to provide freedom of movement. Tape the electrical cord of the pump to the floor. Run the electrical cord of the pump under the carpet.
Obtain a three-prong grounded plug adapter. Explanation: The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard. Taping the electrical cord to the ground and running the electrical cord under the carpet are not appropriate actions for electrical safety Chapter 23: Safety - Page 593
asphyxiation
the state or process of being deprived of oxygen, which can result in unconsciousness or death; suffocation. - Young children and older adults are more vulnerable to toxic fumes. Suffocation, or asphyxiation, can occur at any age, but the incidence is greater in children.
A nurse is making a visit to a client's home and, during the assessment, the nurse notices some possible hazards. What would the nurse identify as potential hazards? Select all that apply. wall-to-wall carpeting clutter on the stairs nonworking smoke detector electrical outlet with several extension cords evidence of mice droppings hair dryer stored in hall cabinet
clutter on the stairs nonworking smoke detector electrical outlet with several extension cords evidence of mice droppings Explanation: Potential hazards in the home include clutter on the stairs, nonworking smoke detectors, overloaded electrical outlets, and evidence of rodents (such as mice droppings). Loose, unsecure carpeting (not wall-to-wall carpeting) and electrical appliances such as hair dryers stored near the tub or sink (and not in a hall cabinet) would be problematic. Chapter 23: Safety - Page 578
The surgical nurse is preparing a client for surgery on the left leg. Which nursing action is appropriate? Select all that apply. Mark the appropriate lower extremity as the one intended for surgery. Have the client mark the body part intended for surgery. Go through a preprocedural verification protocol. Call for a "time-out" immediately before surgery begins. Delegate marking the operative lower extremity to the unlicensed assistive personnel (UAP).
Mark the appropriate lower extremity as the one intended for surgery. Have the client mark the body part intended for surgery. Go through a preprocedural verification protocol. Call for a "time-out" immediately before surgery begins. Explanation: To prevent wrong site, wrong procedure, and wrong person surgery, the nurse will mark the left leg as the one intended for surgery, have the client mark the body part intended for surgery, conduct a preprocedural verification protocol, and perform a "time-out" immediately before surgery to double-check all the surgical information regarding the client and required documents. The nurse will never delegate surgical site identification to a UAP.
A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important? "Make sure that you have smoke detectors in your house and that they're in working order." "If your clothes should catch on fire, go to an open area as quickly as possible." "Make sure that your family's microwave oven was made after 1999; otherwise, it may be a fire risk." "A wood-burning fireplace is a major fire risk, and it shouldn't be used unless necessary."
"Make sure that you have smoke detectors in your house and that they're in working order." Explanation: A paramount fire-safety issue is smoke detectors, since approximately half of home fire deaths occur in a home without a smoke detector. This risk far exceeds that of fireplaces, even though these must be used with caution. Individuals should stop, drop and roll if clothing catches on fire. Old microwaves do not constitute a significant fire risk. Chapter 23: Safety, p. 581, 592-593.
A nurse is providing an in-service program for staff on fire safety and is reviewing the types of fire extinguishers available. Which class of fire extinguisher would the nurse describe as appropriate for use on an electrical fire? Class A Class B Class C Class D
Class C A Class C fire extinguisher is used for electrical fires. Class A extinguisher is used for paper, wood, or cloth fires. Class B extinguisher is used for flammable liquid or gas fires. Class D extinguisher is used for combustible material fires. Chapter 23: Safety - Page 593
A nurse finds a client in his room asphyxiated with carbon monoxide (CO) inhalation. Which activity should be the priority for the nurse? Get the victim out of the present environment. Go to the nursing unit and call for help. Provide oxygen administration and resuscitation. Treat the client with hyperbaric oxygen.
Get the victim out of the present environment. Explanation: The nurse should take the client out of the present environment to prevent further inhalation of carbon monoxide. The nurse can go and call for help after the client has been removed from the site because delay in shifting the client can aggravate the condition. Providing oxygen and hyperbaric oxygen can be given once the client is removed from the site, but the first step is to shift the client from the room. Reference: Chapter 23: Safety, p. 578, 580.
A fire has erupted in the trash can on the unit and the nurse implements the protocol for fire safety for the facility. Another nurse obtains the fire extinguisher and is preparing to use it. What would the nurse do first? Aim the nozzle. Pull the pin. Squeeze the handle. Sweep back and forth.
Pull the pin. Explanation: When using a fire extinguisher, the nurse should follow the PASS mnemonic: Pull the pin, aim the nozzle, squeeze the handle, and sweep back and forth over the fire. Chapter 23: Safety - Page 595
The nurse is caring for a client that is agitated and combative. What action can the nurse take other than the use of physical restraints? Select all that apply. Medicate with benzodiazepines and sleeping agents. Reduce stimulation, noise, and light. Place all four side rails up. Provide a safe environment. Distract and redirect in a commanding voice. Use simple, clear explanations and directions. Use a large plant or piece of furniture as a barrier to limit wandering from the designated area.
Reduce stimulation, noise, and light. Provide a safe environment. Use simple, clear explanations and directions. Use a large plant or piece of furniture as a barrier to limit wandering from the designated area. Explanation: Reducing environmental stimuli, using simple directions, using furniture as safety barriers, and concealing necessary health care devices are appropriate alternatives to restraints. Medicating with behavior- or cognition-altering drugs should be considered a last resort, as they can make the situation worse. Teaching restraint application to significant others and using a commanding voice are not appropriate measures. Provide a safe environment for the client. Chapter 23: Safety - Page 589-591
A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan? Lock all cabinets that contain cleaning supplies. Keep all pots and pans in lower cabinets. Give warm bottles of formula to the baby. Restrain the baby in a car seat.
Restrain the baby in a car seat. Explanation: The client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets, giving warm bottles of formula to the baby, and keeping all pots and pans in lower cabinets are secondary teachings. Chapter 23: Safety - Page 575
A 5-year-old is admitted to the ICU after a head trauma from a bike injury. The child is awake but confused, and continues to pull at IV tubing and a catheter. When the provider orders a restraint, what options would be least restrictive? Select all that apply. four-point soft restraints isolation administration of sedation four side rails up having a parent stay with the child
administration of sedation four side rails up having a parent stay with the child Explanation: The use of four-point restraints and isolation would likely increase agitation. These would be appropriate if behavior was violent or if behavior posed an immediate threat to self or others, such as trying to climb out of the bed. Chapter 23: Safety - Page 588-590
A nurse is caring for an older adult client at risk of injury due to confusion. The client has a stable gait. Which method of restraining should the nurse use? waist restraint locking lap tray chair alarm-activating bracelet vest restraint
alarm-activating bracelet Explanation: The nurse should use an alarm-activating bracelet for the client because the client has a stable gait. This prevents unnecessary confinement to bed, and the client can move freely without getting off the premises. Waist restraints, vest restraints, and chair restraints are restrictive, and their use should be minimal. Chapter 23: Safety - Page 590-591
An anxious son asks the nurse how he can keep his older adult father safe in his home. He tells the nurse that his father lives alone, has chronic illnesses, and also has sensory-perceptual alterations. What is the best statement by the nurse? "A good idea is to get a weekly medicine tray at the pharmacy. This will keep him from missing medication doses or taking the wrong pill by accident." "Put some blocks on his Internet service so he cannot subscribe to disreputable websites." "Small, thick area rugs provide lower extremity warmth in cold weather. He may have temperature deficits in his feet." "If you tried hiding his car keys and he keeps finding them, why don't you disconnect the car battery?"
"A good idea is to get a weekly medicine tray at the pharmacy. This will keep him from missing medication doses or taking the wrong pill by accident." Explanation: Helping older clients dispense the correct dose of medication at the correct time is important to maintaining their homeostasis and prevents possible adverse effects and/or dangerous drug interactions. Blocking Internet sites would be appropriate for children and teens. Small area rugs present a falls risk to older adults, especially if they have visual and mobility issues. Advocating avoidance behaviors like hiding the car keys or disabling the car will serve to create distrust between the father and son. Chapter 23: Safety - Page 597
The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states: "I should be able to fit two fingers between my chin and the chin strap." "The helmet should rest 1 in (2.5 cm) above the eyebrows." "My child needs a helmet if in a secured passenger bike seat." "My child should wear a helmet every time he rides a bike."
"I should be able to fit two fingers between my chin and the chin strap." Explanation: The nurse should determine that additional information is needed when the participant states that the chin strap should fit two fingers underneath the chin. The chin strap needs to be snug, and the ability to fit two fingers between the strap and the chin indicates it is not snug enough. The helmet should rest 1 in (2.5 cm) above the eyebrows. Children should wear a helmet every time they ride a bike or are strapped into a bike seat as a passenger. Chapter 23: Safety - Page 576
The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following? Activate the fire alarm and notify the appropriate person. Attempt to extinguish the fire. Alert the local fire department. Answer all telephone calls and call bells.
Activate the fire alarm and notify the appropriate person. Explanation: RACE stands for Rescue - Alarm - Contain - Extinguish. The "A" in the acronym RACE stands for "activate the fire alarm and notify the appropriate person." Chapter 23: Safety - Page 595
A nurse is applying restraints to a confused client who has threatened the safety of a roommate. Which actions would the nurse perform when properly applying restraints to a client? Select all that apply. Check agency policy for the application of restraints and secure a physician's order. Choose the most restrictive type of device that allows the least amount of mobility. Pad bony prominences. For a restraint applied to an extremity, ensure that the restraint is tight enough that a finger cannot be inserted between the restraint and the client's wrist or ankle. Fasten the restraint to the side rail. Remove the restraint at least every 2 hours or according to agency policy and client need.
Check agency policy for the application of restraints and secure a physician's order. Pad bony prominences. Remove the restraint at least every 2 hours or according to agency policy and client need. Explanation: A restraint can be applied if there is a justifiable reason, such as a client threatening the safety of another client, but a physician's order must be obtained as soon as possible. Bony prominences should be padded to protect skin integrity. The restraint should be removed so the extremity can be moved through range-of-motion and to ensure that circulation is not impaired. The least restrictive type of restraint should be chosen. A finger should be able to fit between the restraint and the body part to ensure the restraint is not too tight. The restraint should be fastened to non-moving parts of the bed. Fastening a restraint to a side rail may cause the restraint to tighten or injure the body part when the rail is lowered or raised. Chapter 23: Safety - Page 590
3. Older adults may be at increased risk of injury related to physiologic factors. Which of the following are relevant risk factors unique to this population? Select all that apply: Decrease in sensory-perceptual function and cognitive judgment Alcohol impairment Impaired thermoregulation Medication side effects
Decrease in sensory-perceptual function and cognitive judgment Impaired thermoregulation Medication side effects Advancing age entails loss in physical function and usually in acuity of sensory-perceptual function (e.g., impaired vision). Older adults may have impaired eyesight and hearing and decreased proprioception to maintain balance and sensitivity to touch. The ability to thermoregulate may become impaired; older adults are at higher risk than younger adults for hypothermia and heat stroke. Reflex responses slow, and the musculoskeletal system can lose flexibility and strength. Various conditions, such as arthritis, osteoporosis, or heart failure, can limit the ability to endure sustained physical activity. Medications taken to control conditions such as high blood pressure or Parkinson disease may result in orthostatic hypotension and increase the potential for falling. Alcohol impairment is not unique to older adults.
An error occurs as the result of the lack of a double-check process on dosing of a high-risk opiate pain medication. The patient becomes oversedated, necessitating reversal of the opioids in order to regain a regular respiratory pattern. Which of the following should the nurse do to document the incident? Select all that apply: Describe factors that led up to the incident Document patient assessment findings following the error Detail contributing factors in patient chart Include interventions needed to reverse oversedation in incident report
Describe factors that led up to the incident Document patient assessment findings following the error Include interventions needed to reverse over-sedation in incident report Documentation of an error in an incident report should completely describe all aspects of the event that occurred. Specifically, the report should include the accident, patient assessment, and interventions provided for the patient. The report is used for internal review to improve the system to prevent similar errors and cannot be subpoenaed by a court of law. This document remains confidential and is not part of the patient's medical record; thus, the incident should not be detailed in the nursing notes or other areas of the patient chart.
What would be the best restraint to use on an infant during care for a head wound? Elbow restraint Waist restraint Extremity restraint Mummy restraint
Mummy restraint Explanation: A mummy restraint is appropriate for short-term restraint for an infant or small child to control the child's movements during examination or to provide care for the head and neck. Chapter 23: Safety - Page 603
The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes? Correct the abbreviations in the EHR. Ask another nurse to fix the abbreviations. Contact the facility's information technology department to delete abbreviations. Suggest to the nurse manager that an in-service on abbreviation use would be helpful.
Suggest to the nurse manager that an in-service on abbreviation use would be helpful. Explanation: Many abbreviations and symbols are not permitted for use in health care records. The nurse should never alter documentation, nor is it appropriate to ask another nurse or the IT department to do so. The nurse should talk to the nurse manager about an in-service on appropriate abbreviation use. Chapter 4: The Nurse's Role in Healthcare Quality and Patient Safety - Page 259-260
A mass casualty event has occurred in a community. Many health care workers have been employed to assist. A nursing student has volunteered services. With which tasks would the nursing student be asked to assist? Select all that apply. Triage clients by severity of injuries. Take clients' vital signs. Obtain extra supplies, such as intravenous bags and tubing, dressings, and gloves. Hold pressure on a wound that will not stop bleeding. Administer intravenous pain medication to a client reporting severe pain.
Take clients' vital signs. Obtain extra supplies, such as intravenous bags and tubing, dressings, and gloves. Hold pressure on a wound that will not stop bleeding. Explanation: In a disaster situation, a nursing student may be assigned tasks such as taking vital signs, obtaining needed supplies, and holding pressure on a bleeding wound. Triage is a critical thinking and clinical decision-making skill the nursing student does not yet have the education or the skill to perform. The nursing student would not be able to administer intravenous pain medications. This would require supervision by a registered nurse, and resources may not be available for this supervision. Chapter 23: Safety - Page 595
A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process? The nurse adds the information in the safety event report to the client health record. The nurse calls the primary health care provider to fill out and sign the safety event report. The nurse provides an opinion of the physical and mental condition of the client that may have precipitated the incident. The nurse details the client's response and the examination and treatment of the client after the incident.
The nurse details the client's response and the examination and treatment of the client after the incident. Explanation: An unintentional injury or incident that compromises safety in a health care agency requires the completion of a safety event report (incident report). The nurse completes the event report immediately after the incident and is responsible for recording the circumstances and the effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. The physician is not responsible for filling out or signing the safety report unless she witnessed the incident. The nurse reports factual information, not opinions. Chapter 23: Safety - Page 596
A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint? a dose of an antipsychotic side rails a geriatric chair with a tray a dose of an analgesic
a dose of an antipsychotic Explanation: Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint. Chapter 23: Safety - Page 589
A nurse is evaluating outcome criteria for a patient following a stroke with Risk for Aspiration assigned as a nursing diagnosis. Which of the following would be appropriate goals for this patient? Select all that apply: The patient will tuck chin for more effective swallow when drinking thin liquids. The patient will avoid drinking liquids related to increased risk for aspiration. The patient will have no signs or symptoms of aspiration (e.g., coughing). The patient will place food on right side to avoid vision cut.
a, c. The patient will tuck chin for more effective swallow when drinking thin liquids. The patient will have no signs or symptoms of aspiration (e.g., coughing). Appropriate goals for this stroke patient are to identify high-risk settings (e.g., drinking thin liquids) and to demonstrate appropriate safety habits (chin tuck). Avoiding drinking liquids is not appropriate at this stage. Compensation for a vision cut is not related to risk for aspiration.
A nurse is assessing a patient for safety upon discharge following a severe cerebrovascular. Which of the following systems would be a priority for this patient's safety? Select all that apply: Neurologic system Cardiovascular system Skin integrity Musculoskeletal system
a, d. Neurologic system Musculoskeletal system For a patient managing deficits following a stroke, neurologic and musculoskeletal system assessments would be a priority. Cardiovascular assessment is not indicated because the cardiovascular capacity is not directly impacted by this diagnosis. Skin assessment may provide important clues to the patient's history of accidents or injuries but would not indicate new risk following a stroke.
Restraints should be used for patient safety in which of the following situations? Select all that apply: The patient is attempting to remove mechanical ventilator tubing. The patient is at risk for falling due to impaired neurologic status. The patient is confused, impulsive, and wants to leave the hospital unit. The patient is combative with staff members.
a, d. The patient is attempting to remove mechanical ventilator tubing. The patient is combative with staff members. Restraints are only clinically justified in selected instances to prevent irreparable harm associated with pulling out therapeutic devices or when endangering self or others. Risk for falls does not indicate restraint use because restraints have not been shown to reduce fall or injury rates and may actually increase incidence of unintended negative consequences. Impulsive behavior and confusion are not indicators for restraints because restraints may increase agitation and injury.
The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include: polypharmacy and use of multiple extension cords. household cleaners stored under the sink and hanging cords on window blinds. peeling paint and easy access to the backyard pool. risky behaviors and cyberbullying.
polypharmacy and use of multiple extension cords. Explanation: Older adults have significant risk of falls at home due to aging changes such as diminished cognition, vision, hearing, and balance. Multiple medications, especially those altering level of consciousness, and household objects that challenge safe mobility, are common dangers. Cleaners, hanging cords, peeling paint, and bodies of water are dangers to young children due to the potential for accidental poisoning, drowning, asphyxiation, and lead toxicity. Risky behaviors and cyberbullying are common issues in the adolescent and young adult age groups. Chapter 23: Safety - Page 579
Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls? places bed at lowest setting provides slippers for ambulation clears a path from bed to bathroom has client sit in bed for a few moments before standing
provides slippers for ambulation Explanation: Older adults often wear slippers to accommodate swollen feet. Although slippers are more comfortable, less expensive, and less tiring to put on than shoes, they do not offer much support or traction. The nurse should intervene to remind the UAP that better footwear should be utilized. Placing the bed at the lowest setting, clearing a path from the bed to the bathroom, and having the client sit in bed before standing increase safety while minimizing risk for falls. Chapter 4: The Nurse's Role in Healthcare Quality and Patient Safety - Page 588
Over the past few weeks, 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 does not comply with a least restraint policy? placing the client in a bed with a bed alarm providing a bed that is low to the floor raising one bed rail to offer stabilization when standing raising all side rails while the client is in bed
raising all side rails while the client is in bed Explanation: Raising all side rails on the bed would be a restraint and may increase the client's risk of falling if he climbs out of bed. All the other options would comply with a least restraint policy. Chapter 23: Safety - Page 589
There is a fire in the neurology unit of a health care facility. What would be most appropriate to avoid in this situation? use of elevators use of stretchers clamping of clients' suction tubes closing of doors and windows
use of elevators The nurses should avoid the use of elevators in a case of fire. They should not avoid the use of wheelchairs and stretchers, as these can be used to evacuate non-ambulatory clients. The nurses should clamp the suction tubes of clients before disconnecting them from the suction apparatus; this helps in transporting the clients faster. The nurses should close doors and windows to reduce the fire's oxygen supply. Chapter 23: Safety - Page 596
A nurse is working as an industrial nurse. Which activity would the nurse suggest that the employers adopt to prevent carbon monoxide (CO) inhalation by the workers? using carbon monoxide detectors and alarms ensuring a good ventilation system at the workplace educating the workers about signs of the presence of CO gas keeping the resuscitation equipment ready at hand
using carbon monoxide detectors and alarms Explanation: The nurse should suggest the use of carbon monoxide detectors and alarms to prevent carbon monoxide inhalation. Ensuring good ventilation is important at the workplace, but it may not be helpful in preventing CO poisoning. The CO gas is odorless; therefore, its presence cannot be detected. Keeping the resuscitation equipment ready is not a preventive measure. Chapter 23: Safety - Page 578
The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which action by the new nurse would require the charge nurse to intervene? waiting outside of the closed bathroom door while the client uses the toilet transferring the client to a room that can be visualized from the nursing station applying an electronic personal alarm placing a "high fall risk" designation on the outside of the client's room
waiting outside of the closed bathroom door while the client uses the toilet Explanation: The nurse should remain with a client who is at high risk for falls. Chapter 23: Safety - Page 588
The nurse is assessing clients for risk factors in the workplace. Which clients would be at risk for injury due to the environment of the workplace? Select all that apply. owner of a fitness center who teaches one yoga class a day medical records technician who works in a doctor's office worker who operates equipment in an automobile assembly plant gardener who mows and places fertilizer on lawns nursing assistant who lifts clients in a nursing home
worker who operates equipment in an automobile assembly plant gardener who mows and places fertilizer on lawns nursing assistant who lifts clients in a nursing home Explanation: Risk factors for injury in the workplace include those occupations in which the client operates dangerous machinery such as in an automobile assembly plant, is exposed to noise and chemicals such as the gardener, and lifts heavy objects such as when the nursing assistant lifts clients in the nursing home. People in the fitness field tend to have low risk of injury and stress. The owner of a fitness center who teaches one yoga class a day has a low-risk factor for injury. The medical records technician, according to CareerCast.com, who works in a doctor's office has low-risk factors for injury. Chapter 23: Safety - Page 578