Chapter 26: Safety, Security, and Emergency Preparedness

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out an electrical fire, what will the nurse identify?

class C Explanation: Class C fire extinguishers contain dry chemicals and are used to extinguish electrical fires. Other answers are incorrect.

The nurse is creating a plan of care for the older adult that has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in reading the labels of his multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance abuse in this client.

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

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

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?

The 2-year-old leaning against the screen of a window in a classroom. Explanation: Windows pose a serious risk to toddlers. Screens can easily give way to the weight of a toddler. This is an unsafe behavior. Toddlers thrive in exploration. The parent must be fastidious in monitoring and helping the toddler accomplish tasks. The buddy system is a great safety tool for school-age children.

The nurse is assessing an adolescent with an annual physical. The mother reports that she has noticed a change in the child's behavior lately including mood swings, withdrawal from the family, and failing school grades. The mother does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse?

"These could be signs of substance abuse. Open communication and a referral to a counselor that specializes in substance abuse would be beneficial." Explanation: Some signs of substance abuse in adolescents include mood swings, withdrawal from the family, and failing school grades. The other statements are inappropriate generalizations and do not address the problem. There is not enough evidence to suggest a need for hospital admission.

A nurse failed to document the administration of a client's warfarin and the nurse on 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?" Explanation: 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 event, but none address the underlying causes, which is the focus of root cause analysis.

The nurse is reviewing a healthcare provider's orders in the electronic health record (EHR) and notices several abbreviations. What is the appropriate nursing action?

Contact healthcare provider to clarify order. Explanation: Before treatments can safely be carried out and medications safely given, the nurse must contact the healthcare provider to clarify the orders. Many abbreviations and symbols are not permitted for use in healthcare records. The nurse should never alter documentation, nor it is appropriate to confirm abbreviations with another nurse.

The nurse is caring for an 80-year-old patient who was admitted to the hospital in a confused and dehydrated state. After the patient 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 patient?

Take the restraints off, stay with her, and talk gently to her. Explanation: 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 patient and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the patient to talk to her is going to cause further agitation and bruising of her wrists. The patient's condition dictates when the patient is discharged, not confusion and agitation.

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?

a dose of an antipsychotic Explanation: Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint.

An 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

automobile accidents. Explanation: Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers.