Chapter 27: Safety, Security, and Emergency Preparedness - ML5

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A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?

Childproofing the house

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 the client's extremity.

The home health nurse is performing fall risk assessments for several new older adult clients. Which factor should the nurse prioritize in developing a care plan to address a high risk for falling? Select all that apply.

Long-term use of benzodiazepines Poor lighting in the home Scatter rugs throughout the home Documented history of previous falls

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter.

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first?

Reduce distressing environmental stimuli to maximize client safety

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply.

Takes furosemide daily Admits to drinking wine through the evening Has history of diabetic neuropathy

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

The alternative measures attempted before applying the restraints

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

The hospital must bear any costs incurred for treating the client's injury.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior


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