Safety Practice Questions

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? 1. Gait belt 2. Jacket harness 3. Four-wheel walker 4. Cane

1

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? 1. Secure the restraints using a quick-release tie. 2. Ensure four fingers fit under the restraints to prevent constriction. 3. Secure the restraints to the lowest bar of the side rail. 4. Anticipate removing the restraints every 4 hr.

1

A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. Which of the following actions should the nurse take first? 1. Extinguish the fire if possible. 2. Activate the fire alarm system. 3. Rescue the client from immediate danger. 4. Confine the fire by closing doors and windows.

3

A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal? 1. The client faces the direction of movement when sliding an object across the floor. 2. When pushing an object, the client moves his front foot backward. 3. When moving an object to one side, the client puts his weight on his heels. 4. The client stands with his feet close together when lifting an object.

1

.Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use? 1. Ask the client's full name and date of birth. 2. Verify the client's room number. 3. Check the client's name on the medication administration record (MAR). 4. Ask a family member to verify the client's identity.

1

A home health nurse is assessing an older adult client who reports falling a couple of times over the past week. Which of the following findings should the nurse suspect is contributing to the client's falls? 1. The client takes alprazolam. 2. The client has a nonslip bathmat in his shower. 3. The client uses a raised toilet seat. 4. The client wears fitted slippers.

1

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check? 1. At the client's bedside before administration 2. In the area where the nurse obtained the medication 3. At the time of documentation 4. At the nurses' station while reviewing the provider's prescription

1

A nurse is preparing to apply wrist restraints to a client to prevent her from pulling out an IV catheter. Which of the following actions should the nurse take? 1. Keep the padded portion of the restraints against the wrists. 2. Ensure enough room to fit one finger between the restraint and the wrist. 3. Attach the ties of the restraint to a non-movable part of the bed frame. 4. Use a knot that will tighten as the client moves.

1

A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first? 1. Determine if the client can bear weight. 2. Place a transfer belt on the client. 3. Position the bed at an appropriate height. 4. Assist the client to a seated position.

1

A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching? 1. "It is a good idea to use the handrails in the bathroom." 2. "I should use chairs without armrests." 3. "I should place a throw rug over electrical cords." 4. "I should get a longer cord for my telephone."

1

A nurse needs to lift a box in a supply room. Which of the following actions should the nurse take to prevent an injury due to lifting? 1. Keep the box close to his body as he lifts. 2. Stand with his feet close together when lifting. 3. Bend at the waist to pick up the box. 4. Twist when placing the box to his side.

1

A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply) 1. Teach balance and strengthening exercises. 2. Provide information about home safety checks. 3. Lock beds and wheelchairs when not providing care. 4. Place the bedside table within the client's reach. 5. Administer a sedative at bedtime.

1, 2, 3, 4

A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.) 1. Document restraint checks and client status every 2 hr. 2. Educate the client's family about restraint use. 3. Obtain the provider's prescription renewal every 72 hr. 4. Implement passive range-of-motion exercises. 5. Release the restraint and reposition the client every 4 hr.

1, 2, 4

A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply). 1. Substance use disorder 2. Age greater than 45 years old 3. Female gender 4. Currently married 5. Schizophrenia

1, 2, 5

A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.) 1. Explain to the client that he will be restrained if he does not stop pulling on his NG tube. 2. Assist the client with toileting at frequent intervals. 3. Use an electronic position-sensitive device. 4. Provide diversionary activities for the client. 5. Involve the family in the client's care.

1, 4, 5

A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? (Select all that apply.) 1. Client's full name 2. Facility room number 3. Partner's full name 4. Provider's name 5. Facility-assigned identification number

1, 5

A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching? 1. "I will tie restraints in double knots." 2. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." 3. "I will ensure that restraints fit tightly against the client." 4. "I will put four side rails up if a client is confused."

2

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply.) 1. Keep the client's room dark at night. 2. Teach the client to use the call light. 3. Keep the client's bed in the lowest position. 4. Place a fall-risk identification band on the client's wrist. 5. Assess the client every 4 hr.

2, 3, 4

A nurse is planning care for a client who has become increasingly anxious and confused. Which of the following actions should the nurse include to avoid the use of physical restraints? (Select all that apply.) 1. Elevate all side rails on the bed. 2. Ensure effective pain management. 3. Attend to the client's needs for toileting. 4. Assign the client to a room near the nurses' station. 5. Orient client frequently to the environment.

2, 3, 4, 5

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? 1. Call the client's provider. 2. Assess the client. 3. Notify the nurse manager. 4. Complete an incident report.

2

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? 1. Place the wheelchair at a 90° angle to the bed. 2. Lock the wheels of the bed and the wheelchair. 3. Acquire the help of several people to lift the client. 4. Elevate the bed to a position of comfort for the nurse.

2

A nurse is caring for a client who is confused and has pulled out her peripheral IV catheter three times. Which of the following actions should the nurse consider? 1. Administer a mild sedative to the client. 2. Place mitten restraints on the client's hands. 3. Reorient the client to time, place, and person. 4. Move the client close to the nurses' station.

2

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? 1. Call the family and ask them to stay with the client. 2. Move the client to a room closer to the nurses' station. 3. Apply wrist and leg restraints to the client. 4. Administer medication to sedate the client.

2

A nurse is planning care for a group of clients. The nurse should identify which of the following clients as having a contraindication for restraints? 1. A client who has a personality disorder and tries to manipulate the staff to gain privileges 2. A client who is recovering from a heroin overdose 3. A client who has an eating disorder and refuses to come to the dining room for meals 4. A client who has obsessive compulsive disorder and insists on mopping the floor in the day room

2

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? 1. Close the fire doors on the unit. 2. Activate the fire alarm. 3. Move any clients in the immediate vicinity. 4. Use a fire extinguisher to put out the fire.

3

19.A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take? 1. Check that the client lifts the walker and then places it down in front of her. 2. Walk in front of the client to guide her in moving the walker. 3. Have the client move one leg forward with the walker. 4. Make sure that the upper bar of the walker is level with the client's waist.

3

A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide? 1. The client has begun playing basketball with several other clients during the past month. 2. The client identifies with problems expressed by other clients. 3. he client's behavior has become impulsive in the past few weeks. 4. The client states she wants to go home to be with her children and partner.

3

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take? 1. Provide support by holding the client's arm. 2. Lean the client toward the wall. 3. Lower the client to the floor. 4. Assume a narrow base of support.

3

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make? 1. "I'll provide more stimulation in his environment." 2. "I will call the doctor and get the prescription." 3. "I will cover the catheter so he cannot see it." 4. "Let's wait until tonight to see if he continues this behavior."

3

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? 1. Limit the client's fluid intake in the evening. 2. Obtain a bedside commode for the client's use. 3. Leave a nightlight on in the client's room. 4. Put the side rails up and tell the client to call the nurse before voiding.

3

A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take? 1. Have another nurse guard the medication preparations until the nurse returns. 2. Have another nurse finish preparing the medications. 3. Lock the medication in a room and finish preparing it after returning from the emergency. 4. Discard the prepared medications and begin again after returning.

3

A nurse manager is observing an AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure? 1. The AP ties the straps of the restraints in a double knot. 2. The AP ties the restraints to the side rails 3. The padding of the restraints is against the client's bony prominences. 4. The nurse can insert one finger between the client's wrist and the restraint.

3

A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide? 1. Premenstrual dysphoric disorder 2. Seasonal affective disorder 3. Major depressive disorder 4. Persistent depressive disorder

3

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? 1. Complete an incident report. 2. Request the risk manager obtain consent for HIV testing from the client. 3. Wash the site of injury with soap and water. 4. Consent to postexposure treatment with antiretroviral medications.

3

A nurse is wearing personal protective equipment and is preparing to leave a client's room after providing care. After untying the ties at the waist of the gown, which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) 1. Remove the mask. 2. Remove the protective eyewear. 3. Remove the gloves. 4. Remove the gown.

3, 4, 2, 1 ???

A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene? 1. Verifies the medication against the prescription and medication label. 2. Scans the bar code on the medication administration record and the client's arm band. 3. Checks the provider's orders and confirmed dosage in a medication reference guide. 4. Documents medication administration prior to administering it.

4

A nurse in an inpatient mental health unit is planning care for a client who is in restraints. Which of the following findings should indicate to the nurse that the client is ready to reintegrate into the unit? 1. The client's vital signs are within the expected reference range. 2. The client requests to use the bathroom. 3. The client eats all of the food provided for each of her meals. 4. The client follows directions.

4

A nurse is administering an IM injection to a client who has hepatitis C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take? 1. Recap the needle. 2. Place the cap on the bedside table and slide the needle into the cap. 3. Wrap the needle with gauze. 4. Dispose of the needle uncapped.

4

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint? 1. The client has a capillary refill of less than 2 seconds. 2. The client has full range of motion in her wrist. 3. The client is attempting to remove the restraint. 4. The client's hand is cool and pale.

4

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints? 1. The provider must renew a restraint prescription every 8 hr. 2. The client must understand the need for the restraints. 3. The restraints should promote the client's safety and prevent injuries. 4. The nurse has already considered alternatives to restraints.

4

A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer? 1. Enlist help from another staff member. 2. Adjust the bed to an appropriate height. 3. Use a powered standing-assist lift. 4. Avoid movements that twist the spine.

4

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? 1. One nurse lifting as the client pushes with his feet 2. Two nurses lifting the client under the shoulders 3. One nurse lifting the client's legs as the client uses a trapeze bar 4. Two nurses using a friction-reducing device

4

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions? 1. "I will keep my walker at the end of my bed." 2. "I will keep the fluorescent ceiling light on in my room at night." 3. "I will place an area rug at the entry of my bathroom." 4. "I will place a bath seat in my shower to use when I bathe."

4

A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include? 1. Relax her abdominal muscles when she lifts an object. 2. Twist at the waist when she moves an object to one side. 3. Hold an object away from her body as she lifts it. 4. Bend at the knees when picking up an object.

4

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.) 1. Bathtub with rails 2. Electric cords behind the furniture 3. Raised toilet seats 4. Water heater temperature 54.4°C (130° F) 5. Throw rugs

4, 5