Chapter 10 Safety

A nurse observes smoke coming from under the door of the staffs lounge. Which of the following actions is the nurses priority?

Move clients who are nearby

The nurse is providing home poison control instruction to the parent of a 2 year old boy. Which statement by the parent indicates the need for further teaching.

''I will give my child syrup of ipecac if he ingest a poisonous substance that is not caustic."

A nurse educator is providing education on infant safety to a group of guardians. Which of the following statements by a guardian indicates an understanding of the teaching?

"I should place the baby on their back when sleeping."

A 6-year-old patient is brought to the emergency department, by their parents, for treatment of an unintentional poisoning from a cleaning product. When providing care to this patient which actions are appropriate?

1. Obtain health history 2. Reach Poison Control Center 3. Syrup of Ipecac is a no go

Before the nurse can intervene, a UAP pushes contaminated material into an overfilled sharps container and sustains a puncture wound. What should the nurse do first? 1. Tell the UAP to immediately report to the infection-control nurse 2. Assist the UAP to scrub the wound with copious amounts of soap and water 3. Report the UAP for improper handling of hazardous material 4. Dispose of the sharps container to prevent any additional injuries to others.

2. Assist the UAP to scrub the wound with copious amounts of soap and water.

An infant has a wound with a dressing on the left upper arm. He repeatedly attempts to remove the dressing. Which SRD would the nurse select? 1. Mummy wrap 2. Wrap jacket 3. Bilateral wrist SRDs 4. Right elbow SRD

4. Right elbow SRD

Types of Fires

A - cloth, wood, upholstery, rubbish, and plastic B - flammable liquids such as grease, gasoline, oil, and oil-based paint C - electrical equipment D - flammable metals E - vegetable oils, animal oils, and fats in cooking appliances

The nurse is teaching a new group of UAPs how to evacuate residents from a long-term care facility in case of a fire or other emergency. Which item would be needed for the universal carry method?

A blanket

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurses priority?

A client who has partial-thickness and full-thickness burns to his face, neck, and chest

A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injured victims. Which of the following clients should the nurse recommend for discharge?

A client who is scheduled for a electric surgery A client who has chronic hypertension and blood pressure is 135/85

when the staffs knowledge of the fire safety precautions is assessed, which action indicates the need for further fire safety instruction?

A heating cord is taped when a frayed area is noted A UAP evacuated critically ill patients on the elevator during a fire drill.

During the 7am to 3pm shift on the adult surgical unit, the code is announced for an external disaster emergency. Which event best represents this type of situation?

A school bus accident

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse must perform?

Aim at the base of the fire

The nurse is caring for a patient on a ventilator and reads the order "restrain prn". The nurse considers which factor when caring for this patient?

Allow as much freedom of movement as possible when applying SRDs Ensure that the nurses two fingers can be inserted between SRD and the patient skin

A licensed practical nurse attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax?

Anthrax can be transmitted by consumption of meat from an infected animal

The postoperative patient demonstrates some mild dizziness and mild shortness of breath when moving from sitting to standing position. Which action would the nurse perform first?

Assist the patient to sit back down

A nurse is caring for a client who has a history of falls. What should she do first?

Complete a fall risk assessment

Contact precautions are initiated for a client with health care associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus(MRSA). The nurse prepares to assist with providing colostomy care and would obtain which protective items to perform this procedure?

Gloves, gown, goggles, and a mask or face shield

A nurse is instructing a client who has COPD about using the orthopedic position to relieve shortness of breath. Which of the following statements should the nurse make?

Have a table beside your bed so you can sit on the bedside and rest your arms on the table.

A nurse notes a fire in a trash can in a clients room. In what order should the nurse take action?

Help the client and others leave the area Pull the fire alarm Close doors Use the fire extinguisher

The older adult residents in a nursing home must be evacuated because the facility is at risk for flooding and damage due to a hurricane that will pass through the area in several days. The nurse is assigned to keep a log to document the events. Which information is most important to record?

How each resident was transported Names of residents Where the residents were sent Who transported each resident Notifications of family and HCPs

The nurse is talking to a young mother who has an infant who has just started to crawl. Based on knowledge of growth and development, which safety issue is currently the most important to discuss with the mother?

How to manage electrical sockets and cords

A home health nurse is assessing a client who experienced extreme exposure to heat and has a body temperature of 104F. The nurse should anticipate that the client will display which of the following manifestation?

Hypotension

A nurse manager is reviewing with nurse on the unit in the care of a client who has a history of falls. Which of the following actions is the nurses priority?

I will go to the nurses station for assistance

A nurse educator is reviewing actions to take in the event of a bomb threat by phone to a group of new nurses. Which of the following statements by a nurse indicates understanding?

I will listen for background noises

The nurse working in the emergency department is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action would the nurse take next?

Isolate the client in a private room

The nurse is planning to teach a community group about fire safety in the home. Which information man would be included in the presentation?

No smoking by the patient, family, or visitors in areas where oxygen is used. Install fire alarms, smoke detectors, and carbon monoxide detectors

An older adult patient in a long-term care facility has been wandering around outside of the room during the late evening hours. The patient has a history of falls. How would the nurse intervene?

Obtain an order for a bed and chair alarm

OSHA

Occupational Safety and Health Administration, a government agency in the Department of Labor to maintain a safe and healthy work environment

The nurse applies a gait belt to a male patient of average build who has some weakness on the left side. How does the nurse position herself before assisting the patient to ambulate?

On the patient's left side and holding the back of the gait belt.

The LPN is reviewing the care plan of the patient who has an SRD applied for personal safety. Which is the highest priority goal for this patient?

Patient will remain free of injury.

Which newly obtained piece of equipment creates the greatest risk for falls for an older adult?

Prescription lenses

The nurse is caring for a client with meningitis and assists to implement which transmission-based precaution for this client?

Private room or cohort client

PASS

Pull, Aim, Squeeze, Sweep

SRD

Safety Reminder Device

The nurse is observing the UAP who is assisting a resident in a long-term care facility to ambulate with a gain belt. Which action by the UAP indicates that further instruction is necessary?

The UAP loosely fastens the gait belt around the patient's waist The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair

A nurse educator is reviewing proper body mechanics during employees orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching?

The lower my center of gravity the more stability I have To broaden my base support I should spread my feet apart When I lift an object I should hold it as close to my body as possible

The occupational health nurse learns of a mercury spill that occurred in the factory in which she is employed. Which action by the nurse is correct?

The nurse evacuates the area and contacts trained personnel to clean up the spill.

The LPN is reviewing the admission information of a patient. Which information is of most concern to the nurse that this patient is at high risk for falling.

The patient wears eyeglasses and a hearing aid

The nurse obtains a prescription to restrain a client using a belt restraint and instructs the assistive personnel to apply the restraint. Which observation, if made by the nurse indicates unsafe application of the spore?

The restraint straps are safely secured to the side of the rails

The nurse is documenting on a patient with an SRD. What information must the nurse include in this document?

The specific type of SRD used and an assessment of the patient.

The nurse would institute which intervention for a client diagnosed with C-diff?

Wear gloves and gown while in the room caring for the client Use soap and water not alcohol-based hand rub, for hand hygiene

Which instructions would be given to the UAP who is assigned to assist in the care of a patient who is being treated with internal radiation?

Wear your personal dosimeter during care or when handling patient items.

The nurse is assisting with creating a plan of care for a client with an internal radiation implant. Which would be included in the plan of care?

Wearing gloves when emptying a clients bedpan Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge when in the clients room Wearing a lead apron when providing direct care to client

The home health nurse is assessing a child for the risk of injury. Which factor places a child at greatest risk for specific types of injuries?

developmental level

A type C fire extinguisher is required for which type of fire?

electrical fires

In the event of a mercury spill, what is the priority nursing action?

evacuate everyone from the roommate

A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?

"I will go to the nurses' station for assistance"

For the care of a patient who has an SRD in place, which task can be delegated to a UAP? 1. Observe for circulation distal to the SRD 2. Check for respiratory effort and breathing 3. Change position every 2 hours 4. Determine when the SRD can be removed

3. Change position every 2 hours

The emergency room department nurse receives a telephone call and is informed that a tornado has hit a local resident area and numerous casualties have occurred. The victims will be brought to the emergency room department. Which would be the initial nursing action?

Activate the agency emergency response plan

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse would take which initial action?

Activate the emergency response plan specific to the facility.

The nurse enters a clients room and finds that the waste basket is on fire. The nurse quickly assists the client out the room. Which is the next nursing action?

Activate the fire alarm

The nurse enters a clients room and the trash is on fire. She removed patients, what is the next thing she should do?

Activate the fire alarm

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the care of plan?

Brush the chemical off the skin and clothing

A parent calls a neighbor who is a nurse and tells the nurse that their 3-year-old child has just ingested liquid furniture polish. The nurse would direct the parent to take which immediate action? 1. Induce vomiting. 2. Call an ambulance. 3. Call the Poison Control Center. 4. Bring the child to the emergency department.

Call the poison control center

A confused patient is yelling at the UAP. As the nurse enters the room, the patient throws the food tray at the UAP. What would the nurse do first?

Calmly talk to the patient and respectfully address him by name

CDC

Center for Disease Control & Prevention; the U.S. government agency at the forefront of public health; mission is to prevent and control infectious and chronic diseases, injuries, workplace hazards, disabilities, and environmental health threats

The nurse is preparing to assist Leigh initiating an intravenous line containing potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no outlet is available in the wall socket. The nurse would take which action?

Contact the electrical maintenance department for assistance.

The nurse is caring for a patient who relies on mechanical ventilation. The nurse hears a fire alarm and flames are visible in a back corridor. What would the nurse do first?

Delegate the UAP to move ambulatory patients toward the exit

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurses priority at this time?

Determine the client's ability to help with the transfer

The home health nurse is visiting an older patient and her husband. What safety concern is the highest priority when the nurse is assessing this patients home environment?

Electrical shock

The nurse is working with an UAP who will be caring for a client who has hand restraints applied. How frequently would the nurse instruct the UAP to remove the restraints to allow muscle activity?

Every 2 hours

The community health nurse is assisting to provide a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective?

Inhalation of bacterial spores Through a cut or abrasion in the skin Ingestion of contaminated undercooked meat

A patient with a latex allergy is exposed to latex. Which sign or symptom is cause for the greatest concern?

Laryngeal edema

A nurse is caring for a client who fell at a nursing home. Theo client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Make sure the clients call light is in reach Provide the client with nonskid footwear Complete a fall risk assessment

In which clinic setting is the nurse most likely to need knowledge of how to apply safety reminder devices and manage the care of these patients?

Mental health walk-in clinic

A patient begins to have a grand mal seizure. What is the priority action?

Monitor the patency of the airway

When caring for the patient who requires the use of an SRD, what should be included in the patient plan of care?

Monitor the skin for signs of impairment Removed the SRD once every 2 hours Reevaluate the need for the SRD frequently

The older adult tells the nurse that he is having trouble reading the labels on his medication bottles. What is the best strategy that the nurse could suggest to reduce the risk of an accidental medical error?

Teach the patient to use a medication organizer to manage the medication

A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include?

Place blankets over the clients who are confined to beds Move beds away from the windows Draw shades and close drapes

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a NG tube. How would the nurse determine that the restraints are too constrictive?

Place two fingers under the restraint to determine snugness

The nurse is reviewing a plan of care for a client with internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision in the plan?

Placing the client in a semiprivate room at the end of the hall

The nurse is caring for a client with a health care associated infection caused by methicillin resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions would the nurse use to perform this procedure?

Put on a mask Don gown and gloves Apply shoe protectors Wear a pair of protective goggles

The nurse notices smoke coming from the wastebasket in a patients room. Upon entering the room, the nurse sees a fire that is starting to flare up. What would the nurse do first?

Remove the patient from the room

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include?

Request assistance when repositioning a client Avoid twisting your spine or bending at the waist Use smooth movements when lifting and moving clients

The nurse started a new job in a small long-term care facility in a rural area. The back exit hallway is being used as a storage area while a new storage area is being planned. What would the nurse do first?

Review the facilities policies/ procedures for emergencies

The nurse obtains a prescription from the RN and primary hcp to restrain a client and instructs a UAP to apply the safety device to a client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the UAP?

Safely securing the safety device straps to the side rails

A nurse is caring for a client who is receiving enteral tube feedings due to dysphasia. Which of the following bed positions should the nurse use for the safe care of this client?

Semi-Fowler's

The nurse discovers smoke in the soiled utility room across the hall from a patients room. What should the nurses initial action be?

Sound the fire alarm

The patient reports dizziness when standing up too fast. Which over the counter medication is most likely to be contributing to the patients orthostatic hypotension?

antihistamine

A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first?

call the poison control center

A nurse is performing a primary survey for a client who has a life-threatening condition. In which order should the nurse perform the assessment.

check the clients airway check the clients ventilation check the clients circulation check the clients level of consciousness check the clients exposure to adverse elements.

The nurse is working in a local health department and has noted an unusually large number of phone calls about food-borne illness. Which question is the nurse most likely to ask callers to differentiate the possible involvement of the bioterrorist agent that causes botulism from other more common causes of food-borne illness?

in addition to gastrointestinal symptoms, have you had drooping eyelids or difficulty swallowing or speaking?

RACE

rescue, alarm, contain, extinguish

It is suspected that a patient has been exposed to cyanide gas. The nurse is alert for which symptom?

respiratory distress