Chapter 21- Patient Safety and Quality

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment B. Educate the client and family about fall risks C. Eliminate safety hazards from the client's environment D. Make sure the client uses assistive aids in his possession

A

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: Place a bed alarm device on the bed. Place the patient in a belt restraint. Provide one-on-one observation of the patient. Apply wrist restraints.

Place a bed alarm device on the bed

At 12 noon the emergency department nurse hears that an explosion has occurred in a local manufacturing plant. Which action does the nurse take first? Prepare for an influx of patients Contact the American Red Cross Determine how to resume normal operations Evacuate patients per the disaster plan

Prepare for an influx of patients

A charge nurse is assigning rooms for clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign the room closest to the nurses' station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy B. A middle adult who requires telemetry for a possible myocardial infarction C. A young adult who is postoperative following an open reduction internal fixation of the ankle D. An older adult who is postoperative following a below-the-knee amputation

D

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds with hemoglobin in the body

D

A nurse is caring for a client who is sitting in a char and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed B. Call for additional staff to assist in the transfer C. Use a transfer belt and assist the client back into bed D. Determine the client's ability to help with the transfer

D

A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure? A. "I will get the caller off the phone as soon as possible so i can alert the staff?" B. "I will begin evacuating clients using the elevators" C. "I will not ask any questions and just let the caller talk" D. "I will listen for background noises"

D

A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. "I will set my water heater at 130 F" B. "Once my baby can sit up, he should be safe in the bathtub" C. "I will place my baby on his stomach to sleep" D. "Once my infant starts to push up, i will remove the mobile from over the crib"

D.

A parent calls the pediatrician's office to ask about directions for using a car seat. Which of the following is the most correct set of instructions the nurse gives to this parent? A. Only infants and toddlers need to ride in the back seat. B. All toddlers can move to a forward facing car seat when they reach age 2. C. Toddlers must reach age 2 and the height/weight requirement before they ride forward facing. D. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.

D.

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 safe care of the client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg

B (will prevent regurgitation and aspiration)

A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should to nurse include in the instructions? (Select all that apply) A. Open doors to client rooms B. Place blankets over clients who are confined to beds C. Move beds away from windows D. Draw shades and close drapes E. Instruct ambulatory clients in the hallways to return to their rooms

B. C. D.

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse education evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

A.

A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assessing the patient's fall risks. Which of the following is the proper order of steps for the "Timed Get-up and Go Test" (TGUGT)?1. Have patient rise from straight-back chair without using arms for support. 2. Begin timing. 3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down. 4. Check time elapsed. 5. Look for unsteadiness in patient's gait. 6. Have patient return to chair and sit down without using arms for support. A. 3, 1, 2, 5, 6, 4 B. 2, 1, 3, 5, 6, 4 C. 1, 2, 3, 6, 5, 4 D. 1, 2, 3, 5, 6, 4

A.

A nurse is educating parents to look for clues in teenagers for possible substance abuse. Which environmental and psychosocial clues should the nurse include? Select all that apply. A. Blood spots on clothing B. Long-sleeved shirts in warm weather C. Changes in relationships D. Wearing dark glasses indoors E. Increased computer use

A. B. C. D.

A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly? Select all that apply. A. Inadequate lighting B. Throw rugs C. Multiple medications D. Doorway thresholds E. Cords covered by carpets F. Staircases with handrails

A. B. C. D. E.

You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following should you include? Select all that apply. A. Drive shorter distances B. Drive only during daylight hours C. Use the side and rearview mirrors carefully D. Keep a window rolled down while driving if has trouble hearing E. Look behind toward the blind spot F. Stop driving at age 75

A. B. C. D. E.

A nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? Select all that apply. A. Check the patient's peripheral pulse in the restrained extremity B. Evaluate the patient's need for toileting C. Offer the patient fluids if appropriate D. Release both limbs at the same time to perform range of motion (ROM) E. Inspect the skin under each restraint

A. B. C. E.

What is your role as a nurse during a fire? Select all that apply. A. Help to evacuate patients B. Shut off medical gases C. Use a fire extinguisher D. Single carry patients out E. Direct ambulatory patients

A. B. C. E.

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply) A. Request assistance when repositioning a client B. Avoid twisting your spine or bending at the waste C. Keep your knees slightly lower than your hips when sitting for long periods of time D. Use smooth movements when lifting and moving clients E. Take a break from repetitive movements every 2-3 hours to flex and stretch your joints and muscles

A. B. D.

A nurse knows that the people most at risk for accidental hypothermia are: Select all that apply. A. People who are homeless. B. People with respiratory conditions. C. People with cardiovascular conditions. D. The very old. E. People with kidney disorders.

A. C. D.

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply) A. "My line of gravity should fall outside my base of support" B. "The lower my center of gravity, the more stability i have" C. "To broaden my base of support, i should spread my feet apart" D. "When i lift an object, i should hold it as close to my body as possible" E. "When pulling an object,i should move my front foot forward"

B. C. D.

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? (Select all that apply) A. Most food poisoning is caused by a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high risk should eat or dink only pasteurized diary products D. Healthy individuals usually recover from the illness in a few weeks E. Handling raw and fresh food separately can prevent food poisoning

B. C. E.

A nurse is providing discharge instructions to a client who has a prescription for oxygen uses t home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply) A. Family members who smoke must be at least 10ft from the client when oxygen is in use B. Nail polish should not be used near a client who is receiving oxygen C. A "no smoking" sign should be placed on the front door D. Colton bedding and clothing should be replaced with items made from wool E. A fire extinguisher should be readily available in the home

B. C. E.

The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and the nurse from injury? Select all that apply. A. If patient is standing, attempt to get him or her back in bed. B. With patient on floor, clear surrounding area of furniture or equipment. C. If possible, keep patient lying supine. D. Do not restrain patient; hold limbs loosely if they are flailing. E. Never force apart a patient's clenched teeth.

B. D. E.

A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by nurse requires further instruction? A. "I will place the client on his side" B. "I will go to the nurses' station for assistance" C. "I will administer his medications" D. "I will prepare to insert an airway"

B. I will go to the nurses' station for assistance

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors on the unit

C

A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? A. Lie on her back with her head and shoulders on a pillow B. Lie flat on her stomach with her head to one side C. Sit on the side of her bed and rest her arms over pillows on top of her beside table D. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her

C (this is the orthopneic position. This allows for chest expansion)

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 int he plan of care? A. Irrigate the affected area with running water B. Was the affected area with antibacterial soap C. Brush the chemical off the skin and clothing D. Leave the clothing in place until emergency personnel arrive

C.

You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. What is the correct order for applying a wrist restraint?1. Be sure that patient is comfortable with arm in anatomic alignment. 2. Wrap wrist with soft part of restraint toward skin and secure snugly.3. Identify patient using two identifiers.4. Introduce self and ask patient about his feelings of being restrained.5. Assess condition of skin where restraint will be placed. A. 4, 3, 5, 1, 2 B. 4, 3, 1, 5, 2 C. 3, 4, 1, 5, 2 D. 3, 4, 5, 1, 2

C.

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? A. A client who received crush injuries to the chest and abdomen and is expected to die B. A client who has a 4-inch laceration to the head C. A client who has partial-thickness and full-thickness burns to his face, neck and chest D. A client who has a fractured fibula and tibia

C. (Has greatest chance of survival with prompt intervention

A nurse on 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 injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply) A. A client who is dehydrated and receiving IV fluids and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and blood pressure 135/85 E. A client who has acute appendicitis and is scheduled for an appendectomy

C. D.

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place and time and can follow directions. Which f the following actions should the nurse take to decrease the risk of another fall? (Select all that apply) A. Place a belt restraint on the client when he is sitting on the bedside commode B. Keep the bed it its lowest position with all side rails up C. Make sure that the client's call light is within reach D. Provide the client with nonskid footwear E. Complete a fall-risk assessment

C. D. E

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. His wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? Select all that apply. A. Smokes a pack a day B. Used a cane to walk at home C. Takes antihypertensive and diuretics D. History of recent fall E. Neglect, spatial and perceptual abilities, impulsive F. Requires assistance with activity, unsteady gait G. IV line, urinary catheter

C. D. E. F. G.

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? Select all that apply. A. Contact the nursing supervisor. B. Restrict the family's visiting privileges. C. Ask the family to stay with the patient if possible. D. Inform the family of the risks associated with side-rail use. E. Thank the family for being conscientious and put the four rails up. F. Discuss alternatives that are appropriate for this patient with the family.

C. D. F.

The nursing assessment of a 78-year-old woman reveals orthostatic hypotension, weakness on the left side, and fear of falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? Activity Intolerance Impaired Bed Mobility Acute Pain Risk for Falls

Risk for falls