Taylor Review Questions - Safety, Security and Emergency Preparedness

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?

Ask to examine the client alone in order to speak to her privately. RATIONALE: In 90% of elder abuse cases that are reported, the person doing the abusing is a family member. The best thing to do would be for the nurse to get the client alone so that she can discuss the relationship that was observed. Documenting the behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury to the client. The nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols.

An order for a waist restraint has been obtained for a client who is a threat to her own safety. The nurse should perform which action?

Insert a fist between the restraint and the client to ensure that her breathing is not constricted. RATIONALE: The client should be in a sitting position. Apply the restraint over the clothing and insert a fist between the restraint and the client to ensure that breathing is not constricted. Assessments should be made every hour to ensure respiration's are not obstructed.

The nurse is caring for a postoperative client with confusion, a weak and unsteady gait, and a history of falls. The chart has an order for a waist restraint. What is the nurse's best next action?

Notify the primary care provider and obtain an order for a client sitter. RATIONALE: The nurse's best next action is to call the primary care provider for a client sitter, an alternative way to provide around-the-clock safety. Alternatives to restraints should be explored first. The client has a postoperative abdominal incision, which is a contraindication for the application of a waist restraint because it would increase intra-abdominal pressure and place strain on the wound. The primary care provider did not order wrist restraints, so the nurse would have to get an order for them, if they were needed. Wrist restraints are applied when a client may try to pull out an intravenous line and harm self from such action. It is not used to help keep the client in bed. The family is out of state and may not be able to come and watch the client around the clock or arrive in a timely manner to be able to help.

A school nurse is preparing an education session on safety for parents of school-age children. What would be an appropriate topic for this age group?

Providing drug, alcohol, and sexuality education. RATIONALE: The school-age child should be taught drug, alcohol, and sexuality education. Selecting toys for the developmental level applies to infants. Teaching stress reduction techniques applies to adults. Providing close supervision to prevent injury applies to toddlers.

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety RATIONALE: The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment.

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk?

She may be the victim of cyber-bullying. RATIONALE: Symptoms of cyber-bullying include faltering school achievement, absenteeism, health concerns, isolating oneself from peers/friends, and increased anxiety and depression symptoms. Adolescents may neglect academics when involved in personal relationships, but that is a common milestone of the age group. Achieving menarche may alter mood, but it is not a risk concern. Nutritional deficits can be seen in adolescence and may need to be investigated with this client, but it is not the priority at this time.

A nurse is volunteering in a free community health clinic. One of the services offered is vehicle restraint checks for children. Which principles apply to infant and child restraints? SATA

Infants should be rear-facing up to the age of 2 years Booster seats should be used until the child is 4ft 9in tall RATIONALE: Infants should remain in the infant seat up to the maximum weight limit or until their length exceeds the length of the seat. Children from 20 to 40 lbs should remain in a forward facing car seat. Due to the force of a deployed airbag, sitting in the front seat is not recommended until the child is 13 years old.

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints?

Investigate the possibility of discontinuing his or her catheter RATIONALE: Discontinuing the catheter, if medically prudent, would eliminate the risks associated with the resident's behavior. Limiting fluid intake or reducing diuretics would be unsafe and ineffective. Similarly, increasing the resident's activity is unlikely to reduce restlessness.

A nurse is providing instructions to the mother of a toddler regarding the prevention of burn injuries in the toddler. Which instruction is the priority to provide to the mother?

Keep coffee cups on the counter above the child's reach RATIONALE: The mother should be told to always keep her coffee cup on the counter so that it is out of reach of the toddler. Toddlers are naturally inquisitive and more mobile than infants, and they fail to understand the dangers of looking into a cup, which can have hot contents. Consequently, they are often the victims of accidental poisoning, falls down stairs or from high chairs, burns, electrocution from exploring outlets or manipulating electric cords, and drowning. The toddler may not understand fire safety or the consequence even after he has been given instructions. A parent feeding the child is not a usual cause of accidental thermal injury.

The nurse is caring for an older client who is ordered restraints. What is the priority nursing action?

Offer the client bathroom privileges and assistance. RATIONALE: Restraints for patients 18 years and older must be removed every 4 hours, six hours is too long. Choosing the least restrictive restraint will help to prevent injury and skin breakdown on body prominences. Keeping arm restraints loose can potentially harm the client. Paper tape is insufficient to secure restraints. The nurse must attend to the client's basic needs regardless of whether he or she is restrained.

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide?

Open doors and windows RATIONALE: Carbon Monoxide (CO) is extremely lethal because it is colorless, odorless, and tasteless. The nurse recognizes symptoms of bright cherry red skin color, nausea, headache and inability to move. The initial direction will be for the caller to open doors and windows to reduce the level of toxic gas and provide adequate ventilation. If, while waiting for emergency personnel to arrive, the family members gain the ability to move, they can evacuate outdoors. After having the caller open the doors and windows, the nurse can then provide instructions about emergency personnel and further discuss CO detectors.

An older adult client is admitted into the hospital due to pneumonia. Which transmission-based precautions should the nurse initiate?

Standard RATIONALE: The nurse should implement standard precautions as these precautions are appropriate for all hospitalized clients. There is no indication that additional precautions such as airborne, droplet or contact precautions are needed at this time.

The nurse is teaching the caregiver of a 1-year-old about safety. Which teaching will the nurse include?

Supervise your child on the changing table. RATIONALE: Infants should be supervised on a changing table. Therefore, it is appropriate to tell the caregiver to supervise the child on the changing table. The other options are not appropriate for infants, but are more appropriate for older children.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

Take the restraints off, stay with her, and talk to her gently. RATIONALE: Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death. The best action in this situation is for the nurse to remove the restraint, stay with the client and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the client to talk to her is going to cause further agitation and bruising of her wrists. The client's condition - not confusion and agitation - dictates when the client is discharged.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event?

The nurse should record the incident in the client's medical record and fill out a safety event report separately RATIONALE: The nurse completes the safety event report immediately after an unintentional injury and is responsible for recording the incident and its effect on the client in the medical record. The safety event report is not a part of the medical record and should to be mentioned in the documentation. The nurse should not wait until after the x-ray to complete the form.

An 8-year-old boy fell off his bicycle. He was not wearing a helmet and has sustained a concussion. What information should the nurse teach the parents about concussions?

"It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness." RATIONALE: Frequent neurologic assessments are crucial after a traumatic brain injury to assess for subtle changes as they begin. Helmets are meant to protect the wearer, but head injury can still occur. "Passing off" an injury as something that kids get and "bounce back" from is wrong and potentially harmful. Watching TV and video games stimulates brain activity and may worsen the child's symptoms and the injury itself.

The facility is conducting an educational seminar for newly employed nurses. The program addresses the reporting of sentinel events. Which occurrences qualify for this criteria? SATA

- A client's baby is misidentified and receives breast milk from another mother - a client faints during ambulation with the nurse, resulting in a concussion - the nurse administers a lethal dosage of medication in error RATIONALE: A sentinel event is one in which a client experiences death or serious injury.

Which clients are most at risk for falling due to altered mobility? SATA

- a client with a spinal cord injury - an older adult client with an unsteady gait - a client who requires crutches in unfamiliar health care settings RATIONALE: Limitations in mobility are unsafe and can cause client injury. The nurse should be aware that clients with spinal cord injuries, older adults with unsteady gaits, and clients who require assistive walking devices such as crutches, especially in unfamiliar health care settings, may be at risk for falling. Not all older adults are at risk for falls. Most females who wear heels are not most at risk for falls, even if they had surgery 2 weeks ago.

Owen is a 15-year-old client who is waking up postoperatively. He became combative and tried to strangle one of the nurses. A support team was called and 4-point restraints were applied in this emergent situation. How soon does a licensed provider need to assess the client and place the restraint order?

1 hour RATIONALE: Restraints can be placed emergency without the order of a licensed provider. However, a face-to-face assessment of the client must be made within 1 hour of restraint placement.

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week RATIONALE: Health care staff who suffer sleep deprivation due to extended work hours and variable shift assignments are more likely to commit errors and to be a factor in adverse events. A nurse transferring to another unit is able to provide care to clients within the scope of practice; this does not present a hazardous situation. Placing three side rails up assists with prevention of falls and is not classified as a restraint. Administering medications to four clients is not a risk factor for hazardous situations.

A new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant?

A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat. RATIONALE: Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should remain in a rear-facing safety seat.

the nurse is assessing a client's mental health competence and decision-making ability. Which activity will best provide the needed information to the nurse?

Ask the client "what if" questions to determine level of thought organization RATIONALE: When reviewing mental health and level of decision making ability, the best method is to ask the client "what if" type of questions. Assessing the client's reading ability and understanding of passages read will not provide the needed information. Asking the client to discuss his medical history will provide some information but will not provide information on his ability to reason and make clear decisions. Questioning the family provides only a secondary source of information and will not be as effective.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate?

Assess for the need to urinate RATIONALE: Client needs should be assessed before considering physical or pharmacologic restraint

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

Assessment of vital signs RATIONALE: Assessment after a head injury includes immediate evaluation of airway, breathing and circulation. Therefore, assessment off vital signs and respiratory status is a priority for this client. Head circumference is only beneficial in children less than 2 years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment. Assessment comes before intervention in the nursing process and more assessment is needed for this client before the need for an IV line is determined.

Which topics should be included in an education plan for preventing falls in the home? SATA

Avoid climbing on a chair or table to reach items that are too high Use a nightlight Remove clutter from walkways Keep electrical and telephone cords against the wall and out of walkways Consider the use of a raised toilet seat RATIONALE: Nurses should teach older clients ways to prevent falls at home. They include the following: clean up clutter. Repair or remove tripping hazards. Install grab bars and handrails. Avoid wearing loose clothing. Lighting should be bright. Wear shoes and make them nonslip. Live on one level. The use of an electronic personal alarm is not a product that would prevent falls.

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?

Avoid unattended baths for the toddler. RATIONALE: The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious. Monitoring the activities of the toddler is not always feasible. Allowing the child to swim with friends does not ensure safety

A nurse in a psychotic care unit finds that a client with psychosis has become violent and is actively trying to harm another client in the unit. What action should the nurse take?

Call for assistance to remove the client from the area. RATIONALE: The nurse should attempt to redirect the client away from the other client with assistance prior to attempting to use force. Stepping in front of the client who is violent may result in the nurse or other personnel becoming injured. Restraints should be a last measure to keep the client under control and avoid injury to the client or others. Injecting a client without their consent is a form of chemical restraint.

Which item would alert the home care nurse to a safety hazard threatening a young child?

Dangling blind cords RATIONALE: As babies gain neurologic and musculoskeletal functions, they learn and explore by pulling objects to themselves and placing almost everything in their mouths. Cords, tablecloths, plastic bags, bottles, and cans are tempting, dangerous objects that caregivers must strive to keep out of reach.

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?

Ensure that two fingers can be inserted between the restraint and client's extremity. RATIONALE: Restraints should be sufficiently loose for two fingers to be inserted between the restraint and the extremity. Restraints can be placed on ankles; quick release knots should be tied to the bed frame, not the side rail. Restraints should be removed every 2 hours

The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize?

Establish the nurse's role during a disaster. RATIONALE: During a disaster, nurses will have multiple roles. In addition to their clinical knowledge, they may be responsible for triage, counseling and various other duties. Fear, panic, anger, and exaggerated concerns are expected. Disaster preparedness is imperative, as well as knowledge of resources. Communication with leadership should be established and sources for realizable information monitored. However, no one of the necessary actions can be performed if the nurse lacks clarity on his or her role.

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death?

Fifth RATIONALE: Unintentional injuries are the fifth leading cause of deaths behind heart disease, cancer, stroke, and chronic obstructive lung disease. Listed are the top 3 leading causes of death in the US: heart disease, cancer, and chronic lower respiratory diseases.

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?

Flush eyes with water for 10 minutes RATIONALE: If poisonous substances have been instilled into the eye, immediately irrigation with lukewarm water for 10-15 minutes may reduce harmful effects.

The nurse is providing teaching to an older adult with arthritis and an implanted catheter. What living arrangement does the nurse anticipate in the discharge plan of care?

Home nursing visits RATIONALE: The nurse anticipates the client will need home care to maintain and care for the implanted catheter, something that may be difficult to do with arthritis. Other answers are incorrect, as the client does not need assisted living, long-term care, or continued admission.

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 RATIONALE: 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 above the eyebrows. Children should wear a helmet every time they ride a bike or are strapped into a bike seat as a passenger.

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?

Initiate use of a bed alarm RATIONALE: To prevent a fall, the nurse should attempt to prevent the confused client from getting out of bed by himself by using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all four side rails and use of a sedative are considered forms of restraints and restraints should be use only as a last resort when the client is in danger of harming himself or others. Contacting the physician for a restraint order or sedative is appropriate if the least restrictive measures do not work.

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner". What is the poison control nurse's appropriate response?

Is you child breathing at this time? RATIONALE: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function, so the nurse will ask about the child's respiratory status. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach; vomiting should not be induced until more information is gathered. Instructing the parent about leaving the child alone is not therapeutic at this time.

The nurse is caring for a school-age child and notices a variety of circular burns on the back and legs in various stages of healing. What action should the nurse take related to this suspicion?

Notify the National Abuse Hotline RATIONALE: All 50 states have laws that require health care personnel to report suspected child abuse. Nurses can report abuse, by contacting the National Child Abuse Hotline. The nurse hustle not delay reporting, because the safety of the child is of utmost importance. The part should not be confronted, because the child may be removed from the facility. Calling the police is not the appropriate action at this time.

The nurse is providing care for an older adult client with a hip fracture utilizing a walker. Which action by the nurse would be the priority?

Place a falls risk bracelet on the client RATIONALE: Nurses are responsible for identifying clients who are at risk for falls and applying intervention to decrease risk and ensure safety. Placing a falls prevention risk bracelet on the client informs all staff and visitors to use care with this client to prevent another fall. Assessing multifunctional status is an important intervention for healing. This client's risk for falls is related to musculoskeletal factors, not neurologic factors. Additionally, 1:1 companionship is not a priority for this client.

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk for falls?

Provide a bedside commode and ensure adequate lighting RATIONALE: The use of a commode can often reduce the risk of falls that is associated with ambulating to the bathroom. Falls reduction is not considered justifiable rationale for catheter insertion. Toileting every 4 hours may or may not be adequate for the client's needs. Fluid intake should never be reduced for the sole purpose of reducing urine output.

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?

Pull the fire alarm lever. RATIONALE: The nurse should pull the fire alarm level. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing.

A client who was receiving care on a psychiatric unit committed suicide at a time when nurses are known to be handing off to nurses on the next shift. What is a responsibility of the organization when responding to this sentinel event?

Report the event to the Joint Commission RATIONALE: Hospitals are required to report serious safety events to regulatory agencies such as the Joint Commission and to state health agencies. There is not formal responsibility to inform other local institutions. There is no obvious need for discipline, though education may be needed. Policies and procedures would be reviewed, but may not need to be changed.

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?

Restrain the baby in a car seat. RATIONALE: 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.

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?

Risk for injury related to agitation RATIONALE: The client's risk of self-injury or injury to others is the justification for restraint use. Restraints are not normally used to address noncompliance or chronic confusion unless there is a consequent safety risk. Impaired bed mobility is not a justification for restraints.

Which reason best explains adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

Social pressure RATIONALE: As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgement.

The nurse is performing a safety belt fit test for a young client at a well-child check-up. What criteria confirms that the child may sit in the back seat of a vehicle with a lap and shoulder belt in place?

The child's feet touch the floor of the care when belted in with the lap and shoulder belt. RATIONALE: The child must meet all of the following criteria to be allowed to sit in the back of a vehicle with a lap and shoulder belt: - The child must sit in the back seat with the entire back against the vehicle's seat back - the buckled seat belt must stay low on the hips and is not resting on the soft part of the stomach - the shoulder belt must lay on the collarbone and shoulder - the child must maintain the correct seating position with the shoulder belt on the shoulder and the lap belt low across the hips

A health care provider has ordered restraints for an older adult client who is delirious from the pain medication she was administered. Which guideline is appropriate for utilizing restraints?

The client's vital sings must be assessed every hour. RATIONALE: The client's vital signs must be assessed every hour when restrained. Restraints must be ordered by a health care provider. Orders for restraints may be renewed every 4 hours for adults 18 years of age or older but must be renewed every 24 hours. chemical restraints do not necessarily have to precede the use of physical restraints.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibility?

The nurse should question the client about the source of the bruises RATIONALE: The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it.

A nurse is teaching parents about internet safety for children. Which actions are recommended guidelines for internet use? SATA

Use filtering software to block objectionable information Investigate any public chat rooms used by the children Be alert for downloaded files with suffixes that indicate images or pictures RATIONALE: Parents should keep identifying information private (ex. Full name, address, telephone number) and investigate filtering software or methods of blocking out objectionable information. They should warn their children to avoid public chat rooms and forums and emphasize that everything said or anything real online may not be true. They should also be alert for downloaded files with suffixes that indicate images or pictures (eg. .jpg, .gif, .bmp, .tif, .pcx) and consider keeping the computer in a central location in the house, rather than in a child's bedroom.

A nurse failed to document the administration of a client's warfarin and the nurse no the next shift administered the drug again, believing that it had been overlooked. When performing root cause analysis in order to identify the essential cause of this error, what question should first be asked?

What could the two nurses have done to ensure this didn't happen? RATIONALE: Asking "why" is essential to the process of root cause analysis. Asking a series of "why" questions can reveal underlying causes. Each of the other listed questions addresses a valid aspect of the vent, but none addresses the underlying causes, which is the focus of root cause analysis.

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers RATIONALE: Medication overdoses are among the more common sources of poisoning in older adults, a phenomenon that can be reduced by ensuring that medications are in clearly labeled containers to avoid administration errors. Cleaning supplies and lead are more significant sources of poisoning in infants and children. Alternative and complementary therapies carry risks, but it would be unnecessary to recommend complete avoidance of all such therapies.

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?

provides slippers for ambulation RATIONALE: 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 off 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

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

within normal limits RATIONALE: A normal white blood cell count is 5,000-10,000 cells/mm3