Safety Pretest (Test #2)

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? a. keep the padded portion of the restrains against the wrist b. ensure enough room to fit one finger b/w the restrains and the wrist c.attach the ties of the restrains to a non-movable part of the bed frame d.use a know that will tighten as the client moves

a. keep the padded portion of the restrains against the wrist--- (to protect skin from abrasion) b. no b/c it should be 2 fingers c. no b/c should attach to movable part of the bed so that change in bed position does not pull on the wrist d.no b/c nurse should use half-bow knot so restrain does not tighten and harm the client when she moves and quickly release in emergency

A nurse is reviewing incident reports submitted during the previous month. The nurse should identify which of the following as a problem that should be reported to the risk manager? a. reports routinely include the client's hospital number b. reports routinely omit the names of the witness to the occurrence c. reports routinely list the identification numbers of any equipment involved reports routinely are completed w/i 24 hrs after incident

b. reports routinely omit the names of the witness to the occurrence a. no b/c hospital number should be included c. no b/c numbers of equipments should be listed and names and dosages of meds d. no b/c reports should be completed w/i 24 hrs following incident

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 restrains? (select all that apply) a.explain to the client that he will be restrained if he does not stop pulling on his NG tube b.assist the client with toileting at frequent intervals c.use of an electronic position-sensitive device d. provide diversionary activities for the client e.involve the family in the client's care.

b.assist the client with toileting at frequent intervals c.use of an electronic position-sensitive device d. provide diversionary activities for the client e.involve the family in the client's care. a no b/c it could be perceived as a threat and pt may not be able to understand

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) .a. keep the client's room dark at night b.teach the client to use the call light c.keep the client's bed in the lowest position d. place a fall-risk identification band on the client's wrist e. assess the client every 4 hr

b.teach the client to use the call light c.keep the client's bed in the lowest position a. no b/c should have night lights or low lightning d. no b/c fall risk band are yellow e. should do hourly rounding at night and every 2 hrs on day time

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? a. complete an incident report b. request the risk manager obtain consent for HIV testing from the client c.wash the cite of injury with soap and water d. consent to post exposure treatment with antiretroviral medications

client c.wash the cite of injury with soap and water a. no b/c not top priority b.no b/c not top priority d. no b/c pt should be treated w/i 1-2 hr after needle stick and continued fro 28 days--if pt was HIV pos another action would take first

An Rn is delegating care activities to a licensed practical nurse (LNP). which of the following is the priority criterion the RN should consider when delegating? a.agency policies for the LPN b.the documented experience level of the LPN c.the documented skill level of the LPN d. State Nurse Practice Act for the LPN

d. State Nurse Practice Act for the LPN a. no b/c consider agency policies to ensure delegation w/i right circumstances b. no b/c nurse should consider documented experience of the LPN to ensure delegation to the right person c. no b/c nurse should consider documented experience of the LPN to ensure delegation to the right person

A nurse in an inpatient mental health unit is planning care for a client who is in restrains. Which of the following findings should indicate the nurse that the client is ready to reintegrate into the unit? a. client's vital signs are w/i the expected reference range b.the client request to use the bathroom c.the client eats all of the food provided for each of her meals d. the client follows directions

d. the client follows directions a.no b/c not an indication that client is ready to reintegrate b. no b/c request is not indication c.no b/c request is not indication

A nurs is applying wrist restrains to a client who is confused and attempting to pull out a chest tube. Which of the following actions should the nurse taking when using restraints? a. Ensure that 1 finger breadth of space is b/w the client's wrist and the restrains b.secure the restrains to the side rails c.remove the restrains to check integrity of the skin every 4hr d. tie the restrains using a quick release knot

d. tie the restrains using a quick release knot a. no b/c it should be 2 fingers breadths b.no b/c should secure to part of bed frame that moves when the head of the bed is raised or lowered c. no b/c should check Q 2hr

A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the provider, and completes and incident report, which of the following actions should the nurse take? a. make a copy of the incident report for the provider b.submit the incident report to the risk manager c.place the incident report in the client's chart d.document in the chart that incidence report has been filed

b.submit the incident report to the risk manager a.no b/c they are confidential tools , never to be copied c. no b/c confidential and never placed in client's chart and protects agains law suit d. no b/c confidential never placed in client's chart and protects agains law suit

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

d.the client's hand is cool and pale a. no b/c does not indicate need to loosen restraint and expected finding b. no b/c does not indicate need to loosen restraint and expected finding c. no b/c its a common reaction and does not indicate nurse to loosen restraint

A nurse is planning care for four clients and is assigning task to a licensed practical nurse (LNP) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN? a. complete an admission assessment for client who has COPD b.Measure I&O for a client who has an indwelling urinary catheter c. Reinforce teaching to a client to being taking enoxaperin at home following a hip arthroplasty d. develop a plan of care for a client who has cholecystitis

c. Reinforce teaching to a client to being taking enoxaperin at home following a hip arthroplasty a. not w.i scope of practice, can contribute to data but not complete the plan of care b.doesn't require license personal to do it -AP can do it d.not w/i scope of practice of LPN, they can contribute

A nurse manager is observing an AP applying wrist restrains for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure? a. The AP ties the straps of the restrains in a double knot b.Th AP ties the restrains to the side rails c. The padding of the restrains is against the client's bony prominences d. The nurse can insert one finger b/w the client's wrist and the restrain

c. The padding of the restrains is against the client's bony prominences a.no b/c should be quick-relate tie incase of emergency b. no b/c should be tied to bed frame, b/c it moves with client d. no b/c should be 2 fingers prevent constriction and possibility of neuromuscular injury

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? a. limit the client's fluid intake in the evening b. obtain a bedside commode for the client to use c. leave a nightlight on in the client's room d. put the side rails up and tell the client to call the nurse before voiding

c. leave a nightlight on in the client's room a. no b/c not appropriate action b.no b/c not appropriate action d.no b/c not appropriate action

A nurs is proving home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching? a.you should hold the cane in your weak hand when ambulating b.you should advance the cane 12-14 inches before taking a step c. you should advance your weak leg forward to the cane, then move your strong leg d. The cane's height should be the same as the distance from the floor to the crest of you hip bone

c. you should advance your weak leg forward to the cane, then move your strong leg a. no b/c hold cane in strong side b. no b/c advance cane 6-10 inches (15-25cm) when walking d. no b/c height of cane should equal distance b/w the floor and the greater trochanter

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

c.I will cover the catheter so he cannot see it a. no b/c nurse should reduce environmental stimuli to try to decrease the client's aviation and confusion b. no b/c nurse should try alternative interventions before applying restraints d no b/c due to concerns of client safety nurse should try to delay addressing the situation

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following should the nurse take? a. provide support holding the client's arm b.lean the client toward the wall c.lower the client to the floor d.assume a narrow base of support

c.lower the client to the floor a. no b/c won't allow support to client and can cause shoulder joint dislocate b. no b/c leaning client to one side alters at the center of the gravity causing distorted balance and making fall more difficult to control d. no b/c nurse should assume a wide base support

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'r priority? a. close the fire doors on the unit b.activate the fire alarm c.move any client's in the immediate vicinity d. use a fire extinguisher to put out the fire

c.move any client's in the immediate vicinity a. no bc/ fire could spread through open doors b no b/c fire could spread w/o emergency services intervention d. no b/c clients are at risk for injury unless someone extinguishes the fire