Foundations of Nursing Chapter 27 Patient Safety and Quality

Which skill is implemented by the nurse when planning to prevent falls in patients? 1 Reviewing the patient's medication 2 Making the patient's environment safe 3 Determining if the patient has a history of recent falls 4 Gathering the equipment and performing hand hygiene

4 During the planning phase, the nurse gathers the equipment and performs hand hygiene. During assessment, the nurse reviews the patient's medication. During implementation, the nurse makes the patient's environment safe. During assessment, the nurse determines if the patient has a history of recent falls.

In a pediatric ward, one of the newborns died of sudden infant death syndrome (SIDS). Which nursing measure lowers the risk of death due to SIDS? 1 Massaging the baby's heels 2 Attaching pacifiers with a string around the baby's neck 3 Gently rubbing the baby's back 4 Having the baby sleep on his or her back

4 Sudden infant death syndrome (SIDS) is a condition in which the infant dies due to an unexplained cause. The American Academy of Pediatrics recommends having the baby sleep on his or her back to reduce the risk of sudden infant death syndrome (SIDS). Massaging the heels helps in managing an apneic episode. Pacifiers should not be attached with a string around the neck, because this increases the risk of choking. Rubbing the baby's back is helpful in stimulating respiration in newborns.

In a health care setting, the restraint order for a patient is renewed every hour. What is the likely age of the patient? 1 6 years 2 14 years 3 23 years 4 65 years

1 In a hospital setting, each original restraint order and renewal is limited to 8hours for adults, 2hours for children ages 9 to 17, and one hour for children under the age of 9. Therefore, a restraint order for a 6-year-old child will require renewal every hour. A restraint order for a 14-year-old patient will require renewal every 2 hours. Restraint orders for the 23-year-old and 65-year-old patients will require renewal every 8 hours.

The nurse teaches the parent of an infant about interventions that promote the child's safety. Which statement by the parent does the nurse find effective for the prevention of choking? 1 "I will immunize my child as recommended." 2 "I will use large soft toys that have no small parts." 3 "I will avoid leaving the mesh sides of playpens lowered." 4 "I will make sure that my child sleeps on the back or side."

2 Small parts of toys may become dislodged. Therefore, the use of large, soft toys without small parts, such as buttons, would prevent choking and aspiration. Immunizing the infant would reduce the risk of sudden infant death syndrome (SIDS). When the mesh sides of a playpen are left lowered, the child's head may become lodged resulting in asphyxiation. The parent should ensure that the child sleeps on the back or side, because this prevents SIDS.

Which patient should be provided with a yellow wristband according to American Hospital Association (AHA)? 1 Patient with allergies 2 Patient with risk of falls 3 Patient with hypothermia 4 Patient who does not require resuscitation

2 The AHA has issued an advisory recommending that hospitals standardize wristband colors. Yellow is issued for patients with fall risks, and red is used for patients with allergies. There is no specific wristband indicated for patients with hypothermia. A purple wristband is given to patients who do not require resuscitation.

The nurse works in the radiology department of a hospital. Which guidelines should the nurse follow with respect to patient safety? Select all that apply. 1 Counsel patients that radiation is not harmful. 2 Ask patients to wear lead aprons when in the radiation zone. 3 Limit patients' time spent near the source of radiation. 4 Make the distance from the source as great as possible. 5 Allow patients to freely move in the radiation zone as desired.

2, 3, 4 Radiation is a health hazard, so hospitals have strict guidelines concerning care of patients receiving radiation. The patient should wear a lead apron to protect against the radiation. The patient should spend a minimum amount of time in the radiation zone and should maintain safe distance from the source of radiation. The patient should be counseled that radiation could be harmful, and the patient should not move freely in the radiation zone.

The registered nurse (RN) is teaching a nursing student about interventions that should be performed in the event of an accidental poisoning. Which statement of the nursing student indicates a need for further teaching? 1 "I will identify the type and amount of the poisonous substance ingested by the victim." 2 "I will irrigate the skin or eye with copious amounts of cool tap water for 15 to 20 minutes." 3 "I will induce vomiting if the victim has ingested furniture polish, grease, or petroleum products." 4 "I will call 911 if the victim is collapsed and initiate CPR if indicated until emergency personnel arrive."

3 In cases in which the victim has ingested furniture polish, grease, or petroleum products, vomiting should never be induced. This may further complicate the victim's condition. In cases of poisoning in the skin or eye, irrigating the skin or eye with copious amounts of cool tap water for 15 to 20 minutes. Identifying the type and amount of substance ingested will help in determining the correct type and amount of antidote needed for treatment. In case the victim has collapsed, 911 should be called immediately. If cardiopulmonary resuscitation is indicated, it should be initiated and performed until emergency personnel arrive.

A patient has been having seizures for more than 30 minutes. The nurse looks after the patient and implements the best efforts to keep the patient safe. Which nursing intervention may lead to complications in the patient? 1 Calling a rapid response team 2 Notifying a health care provider 3 Restraining the patient to prevent injuries 4 Maintaining the airway and administering oxygen

3 Seizures persisting beyond 30 minutes indicate status epilepticus, which is a medical emergency. Restraining the patient further aggravates the injuries during an active episode and should be avoided. Status epilepticus is managed by calling a rapid response team or code blue and notifying a health care provider. The nurse should also take the necessary steps to maintain the airway. If oxygen saturation has dropped to a critical level, then oxygen should be administered.

The nurse is assessing a group of patients in the medical surgical unit and ties colored wristbands (as per the American Hospital Association guidelines) to the patients based on the assessment. Which group of patients should receive red wristbands? 1 The patients who have allergies 2 The patients who are at risk of falling 3 The patients who have a psychiatric illness 4 The patients who have a do-not-resuscitate (DNR) order

1 According to the recommendations of the American Hospital Association (AHA), standardized wristband colors should be used for patients. Red bands should be given to patients with allergies. Yellow bands should be given to patients who are at risk of falls. There is no specific color for identifying patients with psychiatric illness according to the AHA. Purple bands are given to patients who have a do-not-resuscitate (DNR) order.

Which nursing advice should be given to parents to promote safety for their infant? 1 "You should take your infant for immunizations." 2 "You should attach pacifiers to strings or ribbons." 3 "You should place infants on their stomachs to sleep." 4 "You should place large stuffed toys or comforters around the infant when the infant is sleeping."

1 Immunization is advised for a child, because it reduces the risk of sudden infant death syndrome (SIDS). Pacifiers should not be attached to strings or ribbons, because they may cause choking. The best position for children when sleeping is on their back or side, because these positions reduce the risk of sudden infant death syndrome. Large stuffed toys or comforters should not be placed around the child when they are sleeping, because they may cause suffocation or entrapment.

A couple approaches the nurse to seek guidance regarding taking their 10-year-old child on a long ride in a car. During the discussion, the nurse learns that the car has front-seat passenger air bags. What advice should the nurse provide to this couple? 1 Advise that the child ride in the back seat. 2 Suggest that the child ride in the front seat. 3 Suggest keeping the child free from any restraints. 4 Advise of the need for an appropriate car seat for this child.

1 It is safe for a 10-year-old child to ride in the back seat. In case of accidents or a car crash, the child would sustain fewer injuries if seated in the back seat. In case of a sudden stop or a car crash, the child would be susceptible to suffering severe head injuries if unrestrained. Use of seat belts for the child is advised. An appropriate car seat is usually required for children less than 8 years of age or 80 pounds in weight.

The nurse is calculating the fall risk score of an 85-year-old patient using a standard fall assessment tool. Which factors contribute to the patient's overall fall risk? Select all that apply. 1 Age 2 Fall history 3 Gender 4 Weight 5 Medications

1, 2, 5 A fall assessment tool must consider several aspects of a patient's condition and history in order to determine the patient's overall fall risk. The patient's age, fall history, and current medications are considered because older patients are more likely to fall, as are patients with a history of falling, or patients who are on medications that make them dizzy or groggy or that impair their motor skills. Gender and weight are not factors considered in standard fall assessment tools because patients of any gender or weight can be at risk for falling.

A nurse instructs a patient to color code the hot water faucets and dials. What might be the possible age group of the patient? 1 Young adult 2 Older adult 3 Adolescent 4 Preschooler

2 Older adults are instructed to color code the hot water faucets and dials to prevent burns and scalds. The color coding makes it easier for an older adult to know which is hot and which is cold. Young adults and adolescents usually do not confuse hot and cold water, so this suggestion may not be helpful for them. Preschoolers usually need a parent's help taking baths and would not use hot-water faucets and dials.

The registered staff nurse provides various instructions to the caregiver of an infant before discharge from the hospital. Which instruction promotes safety for the infant? 1 Provide pillows and a comforter in the crib. 2 Place the infant in a prone position to sleep. 3 Install deadbolts on exterior doors above the child's reach. 4 The spaces between crib slats need to be 10 cm.

3 Installing deadbolts on exterior doors above the child's reach prevents a crawling infant or toddler from leaving the house and wandering off. Pillows, comforters, or large stuffed toys should not be placed in a crib, because an infant can get twisted in them and suffocate. Infants should sleep on their back or side to help prevent sudden infant death syndrome (SIDS). The spaces between crib slats should be less than 6 cm apart because there is a possibility for a child's head to become wedged between them, and asphyxiation may occur.

Which is a serious reportable event included in the National Quality Forum list? 1 Discharging a patient with a cardiac condition 2 Severe bleeding while removing a foreign object during surgery 3 Disability associated with electric shock during care in a health care facility 4 Bruising associated with the use of bed rails during care in the health care facility

3 The National Quality Forum has compiled a list of serious reportable events that are a major focus of health care providers for patient safety initiatives. Events such as disability or death associated with electric shock while caring for a patient in a health care facility should be reported immediately. Discharging a cardiac patient is not a reportable event. Severe bleeding while performing a surgery is manageable and not a reportable event. Bruising is not a serious complication. Therefore, bruising associated with the use of bed rails during care in the health care facility is not considered a serious reportable event.

Which safety precaution should be taken by the patient with muscle weakness while walking? 1 Using side rails 2 Using crutches 3 Using a belt restraint 4 Wearing rubber-soled shoes

4 Rubber-soled shoes are used by the patients with muscle weakness because they provide better grip on the floor. Side rails are placed on the sides of the bed to help patients in sitting and standing, but would not help the patients with ambulation. Crutches are assistive aids used by the patient who are unable to walk without support. Belt restraints are not used to support ambulation.

The nurse is teaching a group of parents about accidental poisoning. Which are effects of lead poisoning in a child? Select all that apply. 1 Adverse effects on child's growth 2 Learning and behavioral problems 3 Brain and kidney damage 4 Gastrointestinal infection 5 Increased susceptibility to fractures

1, 2, 3 Lead may be found in soil and water systems. It may cause poisoning if inhaled or ingested. Lead poisoning may affect the child's growth and cause learning and behavioral problems. In extreme cases, it may lead to kidney and brain damage. Lead poisoning is not known to cause gastrointestinal infections, because it is not a pathogen. It is also not associated with increased susceptibility to fractures.

A patient sustained a cerebrovascular accident. The patient reports associated weakness on the left side of the body. On further assessment, the nurse learns that the patient has a visual disturbance and uncoordinated gait. How should the nurse ensure the patient's safety? Select all that apply. 1 Eliminate the risk of falls. 2 Consult with a physical therapist. 3 Encourage the use of coping skills. 4 Recommend an assessment of the eyes. 5 Establish a therapeutic relationship.

1, 2, 4 The patient is at a risk of falls due to visual impairment and uncoordinated gait. The nurse should suggest modification of the home environment to prevent risk of falls. A physical therapist should be consulted to help increase muscle strength, balance, and endurance. A visual assessment by an ophthalmologist is important for correction of any visual disturbances. Encouraging the use of coping skills and establishing a therapeutic relationship are helpful to the patient with anxiety-related disorders.

The nurse is caring for a patient who is at risk of falls due to improper gait. Which measures should the nurse take to ensure patient safety? Select all that apply. 1 Apply restraints. 2 Ensure that the patient wears rubber-soled slippers. 3 Move the patient on crutches or walkers after ensuring the patient's integrity. 4 Remove excess furniture from the path. 5 Advise the family members to accompany the patient when the nurse is not present.

2, 3, 4 Use of rubber-soled slippers helps in preventing slips and decreases the risk of falls. The patient should be encouraged to use assistive aids such as crutches and walkers to provide support. Excess furniture can be in the way during ambulation and should be removed. Restraints should not be used, because they can make the patient restless and also increase the risk of immobility-related complications. Family members should be instructed regarding the patient's issues, but it is the nurse's responsibility to take care of the patient.

The registered nurse (RN) is teaching a nursing student about safety for equipment-related accidents. Which statement by the nursing student indicates the need for further learning? 1 "I should use free flow protection devices." 2 "I should place a tag on faculty equipment." 3 "I will make regular safety checks of equipment." 4 "I should not operate the equipment without instructions."

3 The clinical engineering staff, not the nurse, should make regular safety checks of equipment. Free-flow protection devices should be used to avoid rapid infusion of intravenous fluids. When a piece of faculty equipment is found, a tag should be placed on it to prevent it from being used on another patient. Therapy equipment should not be monitored or operated without adequate instructions to avoid accidents. Equipment related accidents may result from malfunction, disrepair, or misuse of equipment or an electrical hazard.

Which nursing activities are performed during safety planning for a patient? Select all that apply. 1 Identify the patient's perceptions of safety needs and risks. 2 Determine impact of the underlying illness on the patient's safety. 3 Determine effect of environmental influence on the patient's safety. 4 Consult with occupational and physical therapists for assistive devices. 5 Select interventions that will improve the safety of the patient's home environment.

4, 5 The nursing activities during the safety planning phase for a patient include consulting with occupational and physical therapists for assistive devices and selecting interventions that will improve the safety of the patient's home environment. When assessing the patient's safety, the nurse should identify the patient's perceptions of safety needs and risks. According to the critical thinking model for safety, determining the impact of the underlying illness on the patient's safety, and the effect of environmental influence on the patient's safety are the nursing activities related to the assessing phase.

What is the correct order of steps for using belt restraints? 1. Place the restraint at the waist. 2. Bring the ties through the slots in the belt. 3. Make the patient roll to the side. 4. Remove the wrinkles in clothing. 5. Apply the belt over the clothes. 6. Place the patient in a sitting position. 7. Help the patient lie down in bed.

6, 5, 1, 4, 2, 7, 3 The first step for using belt restraints is placing the patient in a sitting position in the bed. The second step is applying the belt over the patient's clothes, gown, or pajamas. The next step is making sure to place the restraint at the waist, and not in the chest or abdomen. This step is followed by removing wrinkles or creases in the clothing. Then, the patient should be helped to lie down in bed. The last step is helping the patient roll to the side.

The physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the steps for applying the restraint in the correct order. 1. Explain what you plan to do. 2. Wrap a limb restraint around wrist or ankle with the soft part toward the skin and secure. 3. Determine that restraint alternatives fail to ensure patient's safety. 4. Identify the patient using proper identifier. 5. Pad the patient's wrist.

3, 1, 2, 4, 5 Because the patient is pulling out a surgical wound drain, the first step is determining that restraint alternatives fail to ensure patient's safety. Next, identify the patient using the proper identifier and then explain what you plan to do. Next, pad the patient's wrist and finally, wrap a limb restraint around the wrist or ankle with the soft part toward the skin and secure.

The nurse is teaching a group of nursing assistive personnel about the types of fire extinguishers. Which type of fire can be extinguished using a type A fire extinguisher? Select all that apply. 1 Wood 2 Cloth 3 Gasoline 4 Paper 5 Paint

1, 2, 4 A type A fire extinguisher is used to extinguish fire caused by ordinary combustible materials such as wood, cloth, or paper. Fire caused by gasoline and paint is extinguished by type B fire extinguishers.

The nurse works in a nursing home. Of which are common causes of death in the elderly population that the nurse should be aware? Select all that apply. 1 Falls 2 Poisoning 3 Hypothermia 4 Heat stroke 5 Motor vehicle accident

1, 3, 4 Falls are a common cause of accidental death in elderly patients due to poor vision, gait and balance problems, and the effects of various medications. Hypothermia and heat stroke are also common causes of death in the elderly, becuse they are more vulnerable to temperature changes. Poisoning is more common in toddlers and small children, because they have a habit of ingesting chemicals such as cleaning solutions and medicines found in the house. Motor vehicle accidents are a more common cause of death in younger adults than in the elderly.

The registered nurse (RN) is teaching a group of patients from a vulnerable population regarding measures to prevent fires at home. Which statement by a member of the group indicates the need for further teaching? 1 "We should avoid smoking at home." 2 "We should use old model space heaters." 3 "We should use the cooking equipment effectively." 4 "We should place carbon monoxide detectors in the house."

2 The U.S Consumer Product Safety Commission estimates that more than 25,000 residential fires every year are associated with the use of space heaters. Therefore, families should be advised to use only newer-model space heaters that have all of the current safety features. The leading cause of fire-related death is careless smoking, especially when smoking in bed. Therefore, smoking should be completely avoided. The improper use of cooking equipment and appliances are the main source of in-home fires and fire injuries. Therefore, families should be taught about effective use of cooking equipment. Smoke detectors and carbon monoxide detectors should be placed throughout the home.

Which age group is at the highest risk for accidental poisoning at home? 1 Adults 2 Toddlers 3 Older adults 4 Adolescents

2 oddlers, preschoolers, and young school-age children are at greater risk for accidental poisoning at home, as they tend to put objects in the mouth. Adults, older adults, and adolescents are generally not prone to accidental poisoning at home, because they are knowledgeable of poisonous substances.

The nurse is teaching the mother of a school-age child about interventions to promote safety. Which statement made by the mother indicates the need for further teaching? 1 "I should teach child proper bicycle safety." 2 "I should teach my child about the effects of using alcohol and drugs." 3 "I should teach my child the safe use of equipment for play and work." 4 "I should teach my child to operate electrical equipment under supervision."

2 The mother does not need to teach a school-age child about the effects of using alcohol and drugs at this age. This intervention would be more appropriate for adolescents, because they are more prone to risk-taking behaviors. The mother should teach the child about proper bicycle safety to reduce the risk of falls. The mother should teach the child the safe use of equipment for play and work to avoid injury. The mother should teach the child to operate electrical equipment only under supervision.

While caring for a patient with left-sided weakness, the nurse suspects anxiety related to fear of falling. Which assessment findings would further confirm the nurse's suspicion? Select all that apply. 1 Difficulty seeing distant objects 2 Difficulty focusing during conversations 3 Difficulty understanding medication instructions 4 Limited ability to perform fine and gross motor skills on the left side 5 Moving the head to the right side in response to loud noises on the left side

2, 3 If a patient has difficulty focusing or difficulty understanding teaching during a conversation, it may indicate anxiety related to fear of falling or health status. When the patient exhibits a limited ability to perform fine and gross motor skills on the left side, it indicates impaired physical mobility. If the patient has difficulty seeing objects at a distance, the patient is at risk of falls. Unresponsiveness of the patient to loud noises on the left side indicates unilateral neglect related to brain injury.

A registered nurse (RN) is teaching a parent about safety measures for a 5-year-old child. Which statement made by the parent indicates the need for further learning? 1 "I should teach the child about bicycle safety." 2 "I should teach the child about safety during specific sports." 3 "I should teach the child how to operate electrical equipment." 4 "I should teach the child about safe use of equipment for play and work."

3 Children should be taught not to operate electrical equipment, because an electrical mishap may occur. Bicycle safety should be taught to children to reduce injuries from falling. Safety during sports should be taught to children to protect them from injuries. The children should be taught about safe and appropriate used of equipment to avoid injuries.

The nurse is caring for an older adult in a health care setting and follows interventions to reduce the risk of tripping. Which intervention does the nurse implement in this situation? 1 Cleaning all spills promptly 2 Ensuring adequate glare-free lighting 3 Keeping the floor free of clutter and obstacles 4 Having assistive devices on the exit side of the bed

3 The nurse keeps the floor free of clutter and obstacles to reduce the risk of falling or tripping. The nurse cleans all spills promptly to reduce the risk of slipping on wet surfaces. The nurse ensures adequate glare-free lighting, becauseit may be a problem for older adults because of vision changes. The nurse keeps assistive devices on the exit side of the bed to provide added support when transferring out of bed.

The nurse is admitting a 64-year-old patient who had a right hemisphere stroke and a recent fall. The spouse stated that the patient has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently the patient exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. The patient has moderate left-sided weakness that requires the assistance of two nurses and the use of a gait belt to transfer the patient to a chair. The patient currently has an intravenous (IV) line and a urinary catheter in place. Which factors increase the patient's fall risk at this time? Select all that apply. 1 Smokes a pack a day 2 Used a cane to walk at home 3 Takes antihypertensive and diuretics 4 History of recent fall 5 Neglect, spatial and perceptual abilities, impulsive 6 Requires assistance with activity, unsteady gait 7 IV line, urinary catheter

3, 4, 5, 6, 7 Smoking is not a risk factor for falls. Using a cane at home is not a current risk factor for falls. Risk is determined by the patient's current status.

Which patients are at higher risk of motor vehicle accidents according to the Centers for Disease Control and Prevention (CDC)? 1 2-year-old patient 2 30-year-old patient 3 55-year-old patient 4 16-year-old patient

4 According to the CDC, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age group, because teens are more likely to underestimate dangerous situations. A 2-year-old patient is not at elevated risk of motor vehicle accidents, because 2-year-olds do not use motor vehicles. A 30- or 55-year-old adult is not at elevated risk of motor vehicle accidents according to the CDC.

The registered nurse (RN) is teaching a patient's family members about environmental assessments for substance abuse. Which statements should the nurse include in the teaching? Select all that apply. 1 "You should observe for increased aggressiveness." 2 "You should check for the changes in style of dress." 3 "You should observe for changes in interpersonal relationships." 4 "You should check for the presence of drug-oriented magazines." 5 "You should observe for the presence of blood spots on clothing.

4, 5 The environmental clues that indicate substance abuse are the presence of drug-oriented magazines and the presence of blood spots on the patient's clothing, which could be caused by the injection of drugs into the body. Increased aggressiveness, changes in style of dress, and changes in interpersonal relationships are psychological clues that indicate substance abuse.

According to Edelman and Mandle's strategies of health promotion, which is classified as a passive strategy? 1 Clean water laws 2 Exercise programs 3 Wearing seat belts 4 Nutrition programs

1 A safe environment and a healthy lifestyle are necessary for health promotion. Clean water laws are considered passive strategies of health promotion. Passive strategies include public health and government legislative interventions. Exercise programs, wearing seat belts, and nutrition programs are considered active strategies of health promotion. An active strategy involves lifestyle changes.

Which task is delegated to nursing assistive personnel (NAP)? 1 Checking on a restraint 2 Assessing a patient's behavior 3 Applying restraints appropriately 4 Orientating the patient to the environment

1 Checking on a restraint can be delegated to nursing assistive personnel (NAP). Assessing a patient's behavior, orientating the patient to the environment, and determining the need and appropriate use of the restraints should be performed by the nurse and are not delegated to NAP.

While caring for a patient with epilepsy, the nurse recognizes the possibility of tonic-clonic seizure. What is the priority intervention by the nurse? 1 Inserting a bite-block 2 Helping the patient to stand 3 Conducting a head to toe evaluation 4 Notifying the primary health care provider

1 During a seizure, the patient may clench the teeth, which could damage the mucous membranes of the oral cavity. The teeth can also become broken. Therefore, the nurse should immediately insert a bite-block in advance. The nurse should not position the patient to stand. Instead, the nurse should assist the patient to bed. A head to toe evaluation would be appropriate after the seizure attack. The nurse may notify the primary health care provider after inserting the bite-block.

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. What should the nurse consider when providing discharge teaching about home safety to this patient and her husband? 1 A safe environment promotes patient activity. 2 Assessment focuses on environmental factors only. 3 Teaching home safety is difficult to do in the hospital setting. 4 Most accidents with the older adult are caused by lifestyle factors.

1 Older adults are frequently fearful of falling and thus often limit activity. A safe environment, which decreases the risk of a fall, promotes patient activity.

What is the leading cause of injuries involving home medical oxygen? 1 Smoking 2 Lead poisoning 3 Exposure to severe cold for long periods 4 Exposure to high concentrations of carbon monoxide

1 Smoking is the leading cause of burns, reported fires, deaths, and injuries involving home medical oxygen. Exposure to severe cold for prolonged periods of time causes frostbite and accidental hypothermia. Exposure to excessive levels of lead poisoning may lead to learning and behavioral problems in children, as well as brain and kidney damage. Exposure to high concentrations of carbon monoxide may cause death within 1 to 3 minutes.

Which is a serious reportable event included in the National Quality Forum List? 1 Immediate postoperative death 2 Hypothermia due to severe cold conditions 3 A fall associated with administration of diuretics 4 Injury resulting from physical assault that occurred at a patient's home

1 The National Quality Forum has compiled a list of serious reportable events that are the major focus of health care providers for patient safety initiatives. Events such as intraoperative or immediate postoperative death should be reported immediately because they are serious reportable events. Hypothermia due to severe conditions is not included on the list. Likewise, a fall associated with administration of diuretics is not listed as a serious reportable event. Injury due to physical assault in the health care facility, not at a patient's home, is a serious reportable event included on the National Quality Forum List.

At 3 AM the emergency department nurse hears that a tornado hit the east side of town. Which action should the nurse take first? 1 Prepare for an influx of patients. 2 Contact the American Red Cross. 3 Determine how to restore essential services. 4 Evacuate patients per the disaster plan.

1 The emergency department nurse first needs to prepare for the potential influx of patients. Staff should be aware of the disaster plan. Patients may need to be evacuated but not initially. The American Red Cross is not contacted initially. Determination of how to restore essential services is part of the disaster plan and is determined before an actual event.

The nurse is caring for a patient in the home and is checking for hazards. Which assessment made by the nurse is priority? 1 Assessing the adequacy of light 2 Assessing the presence of safety devices 3 Assessing the locks to doors and windows 4 Assessing the kitchen and bathroom for safety

1 When the nurse is caring for the patient at home, the priority action is to assess the adequacy of light. Sufficient lighting in the room ensures that everything is visible and reduces the risk for injuries. The presence of safety devices, the presence of locks, and the kitchen and bathroom should be assessed after the adequacy of light is assessed.

A patient is confused and has become violent after recovering from a seizure episode. How should the nurse reorient this patient and provide further care? Select all that apply. 1 Answer the patient's questions. 2 Explain what happened. 3 Leave the patient alone. 4 Offer coffee or tea. 5 Expect the patient to reorient as time passes.

1, 2 Once the patient gains consciousness, the patient may be disoriented. The nurse should reorient and reassure the patient by acknowledging what happened and answering any questions. Every attempt should be made to stay with the patient throughout recovery. In the recovery phase, the patient will be drowsy and should be allowed to sleep. The patient should not be offered coffee or tea, because they stimulate the central nervous system and may not allow the patient to sleep. Even though patients become reoriented on their own, the nurse should make an attempt to reorient the patient so that the patient gains a better understanding of the situation.

Which questions should the nurse ask a patient to determine environmental comfort in a patient's home? Select all that apply. 1 "Are you using space heaters?" 2 "Are you using an air conditioning system?" 3 "Are your fire extinguishers routinely serviced?" 4 "Do you keep spoiled vegetables in the refrigerator?" 5 "Do you check the expiration date of milk products before eating them?"

1, 2, 3 Assessment of the environmental comfort of a patient's home includes a review of the usage and maintenance of space heaters, air conditioning systems, and fire extinguishers. Assessment for the risk of food infection or poisoning includes assessing a patient's knowledge about food preparation and storage practices such as whether he or she keeps food in the refrigerator until it spoils and checks the expiration dates of food products.

Which interventions are followed by the nurse to protect older adults in acute care settings? Select all that apply. 1 Providing bed rails for safety 2 Keeping the environment free from clutter 3 Explaining and demonstrating how to use the call light 4 Responding quickly to call lights and bed/chair alarms 5 Placing the call device close to the patient before a nurse-patient interaction

1, 2, 3, 4 The nurse should provide bed rails to prevent falls in older adults, keep the environment free from clutter, explain and demonstrate the use of call lights, and respond quickly to call lights and bed/chair alarms. The call devices are given to patients at the end of the nurse-patient interaction.

The nurse has used restraints for a disoriented patient. Which reasons would justify the use of restraints? Select all that apply. 1 To help reduce the risk of patient injury from falls 2 To prevent the patient from removing IV infusions 3 To help to control the patient 4 To help to reduce the risk of injury to others by the patient 5 To minimize the need for supervision of the patient

1, 2, 4 Restraints are a means to maintain patient safety. Nurses use restraints to protect patients who are confused, disoriented, repeatedly fall, or try to remove medical devices such as intravenous (IV) infusions or oxygen equipment. A disoriented patient can harm others and should be restrained. A restraint is not used to control the patient or to discontinue care.

The nurse is caring for a patient who sustained a femur fracture following a fall. Which common physical hazards can increase the risk of falling? Select all that apply. 1 Inadequate lighting 2 Barriers in the normal walking path 3 Sudden decrease in blood glucose levels 4 Lack of safety devices in homes 5 Sudden rise in blood pressure

1, 2, 4 Common physical hazards that increase the risk of falls are inadequate lighting, barriers in the normal walking path, and lack of safety devices in homes. Although a sudden decrease in blood glucose levels and a sudden increase in blood pressure may increase the risk of fall, these are not physical hazards.

Which patients are at high risk of hypothermia? Select all that apply. 1 Patients who have angina 2 Patients who are homeless 3 Patients who have kidney disorders 4 Patients who have taken a drug overdose 5 Patients who are exposed to carbon monoxide

1, 2, 4 Patients with cardiovascular disease such as angina, people who are homeless, and people who have ingested drugs or alcohol in excess are at high risk for hyperthermia. Patients with kidney disorders are not at elevated risk of hypothermia. Patients who are exposed to high concentrations of carbon monoxide may have a risk of death.

The nurse finds that a patient has sustained seizures lasting longer than 5 minutes. Which strategies should be included in the care plan to prevent hypoxia in this patient? Select all that apply. 1 Suctioning the airway 2 Maintaining a patent airway 3 Placing in prone position 4 Providing oxygen via nasal cannula 5 Inserting an oral airway

1, 2, 4 Seizures beyond 5 minutes may deprive the patient of oxygen. Suctioning should be performed, bevcause it is needed to keep the airway patent. The airway and oxygenation should be maintained either via nasal cannula or a face mask. Placing the patient in prone position would obstruct the airway and thus should be avoided. An oral airway should be attempted only if access is easy and the breathing is impaired.

A patient sustained minor burns in a fire at home. After stabilizing the patient, the nurse asks the patient to obtain a fire extinguisher at home. Which instructions should the nurse provide to the patient? Select all that apply. 1 It should be inaccessible to the children. 2 It should be placed on each level near an exit. 3 It should be kept at a low level in the room. 4 It should be placed in clear view. 5 It should be kept away from stoves and heating appliances.

1, 2, 4, 5 Fire extinguishers should be placed where they are inaccessible to children. Children may play with this equipment, which may lead to accidents. To enhance fire safety, a fire extinguisher should be placed on each level of the home and near the exit doors so that it is reachable when required. The extinguishers should be easily visible so that they can be accessed when required. They should be placed away from stoves and heating appliances to prevent explosion of the equipment. They should not be placed at a low level in a room. If one is placed at a low level, it would be accessible to children, which can lead to accidents

A nurse is performing Timed Get up and Go (TUG) for a patient. What is the correct order of steps in in which the assessment will be performed? 1. Give verbal instructions to stand up and walk 10 feet as quickly and safely as possible. 2. Begin counting. 3. Have the patient rise from a straight back chair without using arms for support. 4. Check time elapsed. 5. Look for unsteadiness in the patient's gait. 6. Have the patient return to the chair and sit down without using arms for support.

1, 3, 2, 5, 4, 6 The first step while performing TUG is giving verbal instructions to stand up and walk 10 feet as quickly and safely as possible. The next step is having the patient rise from a straight back chair without using arms for support. This is followed by beginning to count. The next step is looking for unsteadiness in the patient's gait. The nurse then has the patient return to the chair and sit down without using the arms for support. The last step is to check the time elapsed.

The nurse accompanies a patient for an x-ray. How does the nurse reduce exposure to radiation? Select all that apply. 1 Using lead aprons while entering the x-ray unit 2 Wearing a normal apron while entering the x-ray unit 3 Limiting the time spent near the source of the radiation 4 Maintaining the proper distance from the source of the radiation 5 Wearing a black apron while entering the x-ray unit

1, 3, 4 To reduce the risk of exposure, the nurse should wear a lead apron when entering radiation rooms, limit the time spent near the source of the radiation to limit the duration of radiation, and maintain a safe distance from the source to reduce the dose of radiation. Normal aprons and black aprons do not protect from radiation exposure and hence should not be worn when entering the radiation rooms.

The nurse is caring for an older adult in the home. The nurse is concerned about the risk of injury. Following an assessment, the nurse finds that the patient has visual impairment. Which actions should the nurse perform to reduce the risk of injury for this patient? Select all that apply. 1 Keep the home well lit. 2 Keep the rooms ventilated. 3 Keep clean eyeglasses at hand. 4 Teach range-of-motion exercises. 5 Perform a home hazard assessment.

1, 3, 5 Keeping the home well-lit will help the patient see objects without trouble. Clean and protected eyeglasses at hand will help the patient see clearly. During the home hazard assessment, the nurse should walk through the home with the patient and discuss how the patient normally conducts daily activities and whether the environment poses problems. Keeping the rooms ventilated may not help the patient in reducing risk of injury. Range-of-motion exercises may be performed by patients with altered mobility.

A patient has recovered from seizures in a postoperative ward. How should the nurse ensure continued safety of the patient? Select all that apply. 1 Raise the side rails of the bed. 2 Place the patient in supine position. 3 Keep the call light and intercom near the patient. 4 Avoid the use of pillows. 5 Place the bed in the lowest position.

1, 3, 5 To ensure continued safety of a patient following seizures, the side rails of the bed should be raised to prevent a fall. Placing the call light and intercom within reach of the patient would help in receiving assistance, if needed. The bed should be lowered to the lowest position to prevent a fall and risk of injury. The patient should be positioned lying on the side, not in the supine position. Lying on the side prevents the tongue from falling back and obstructing the airway. A pillow should be used to support the head once the seizure is over.

Which questions if asked by the nurse are useful for evaluating a patient's perception of safety? Select all that apply. 1 "Are you still afraid of falling?" 2 "What factors led to your fall?" 3 "What questions do you have about your safety?" 4 "Do you feel safer as a result of the changes in home?" 5 "Do you need help locating community resources to help make your home safer?

1, 4 Questions such as "Are you still afraid of falling?" and "Do you feel safer as a result of the changes?" help the nurse understand the patient's perceptions related to safety. When patient outcomes are not met, the nurse should ask questions such as "What factors led to your fall?" "What questions do you have about your safety?" and "Do you need help locating community resources to help make your home safer?"

A patient is brought to the emergency room in an unconscious state. On taking the history the nurse finds that the patient had accidentally consumed agricultural pesticides. Which intervention will prevent the potential of aspiration in this patient? 1 Avoiding the use of nasogastric tubes in the patient 2 Positioning the patient with head turned 3 Positioning the patient with head straight 4 Making arrangements for suctioning of the secretions

2 An unconscious patient is susceptible to aspirating the stomach contents into the bronchial tree. Positioning the patient with head turned prevents aspiration. Nasogastric tubes also prevent aspiration of secretions, because they do not allow the stomach contents to aspirate into the bronchial tree. If the patient's head is held straight, there is a higher chance of aspiration. Suctioning has no preventive role in aspiration, but it helps to remove active secretions of the lungs.

Which nursing activity is performed during the assessment of a patient? 1 Selecting nursing interventions to promote safety 2 Identifying patient perceptions safety needs and risks 3 Consulting with occupational and physical therapists for assistive devices 4 Selecting interventions that will improve the safety of the patient's home environment

2 Identifying the patient's perceptions of safety needs and risks is involved in the critical thinking model for safety assessment. The critical thinking model for safety planning involves selecting nursing interventions to promote safety, consulting with occupational and physical therapists for assistive devices, and selecting interventions that will improve the safety of the patient's home environment.

In a hospital, a use of restraint is ordered and renewed every two hours. What might be the age of the patient? 1 8 years 2 15 years 3 21 years 4 35 years

2 In hospital settings, each original restraint order and renewal is limited to 8 hours for adults, 2 hours for ages 9 to 17, and 1 hour for children under age 9. Therefore, a 15-year-old patient will require ordering and renewing of the restraint order every 2 hours. The 8-year-old child will require ordering and renewal every 1 hour. The 21-year-old and 35-year-old patients will require renewal every 8 hours.

According to the National Quality Forum, which event is included under patient-protection events? 1 Abduction of a patient 2 Infant discharge to the wrong person 3 Disability associated with a medication error 4 Surgery performed on the wrong body part

2 Infant discharge to the wrong person is included under patient-protection events. Events like the abduction of a patient are considered to be criminal events. Disability associated with a medication error is included under care-management events. Surgeries performed on the wrong body part are included under surgical events.

The registered nurse is teaching the parent of a toddler about interventions to promote safety. Which statement made by the parent indicates the need for further teaching? 1 "I will place window guards on all the windows. " 2 "I will avoid installing safety locks on floor-level cabinets. " 3 "I will install keyless locks on door above my child's reach. " 4 "I will avoid using infant seats and swings when the child becomes too active. "

2 Installing safety locks on floor-level cabinets helps to baby-proof the home and prevent toddlers exploring their world with their hands and mouth. Therefore, it decreases the risk of choking and poisoning. Placing window guards on all the windows would be beneficial to prevent children from falling out of windows. Installing keyless locks on the door out of the child's reach prevents the child from leaving home and wandering off. It is very important to avoid the use of infant seats and swings when the child becomes too active, because the child may fall out of or trip over these accessories and may suffer injury.

What is the correct order of steps for safely using a fire extinguisher in the home? 1. Squeezing the handle 2. Pulling the pin to unlock the handle 3. Aiming low at the base of the fire 4. Sweeping the unit from side to side

2, 3, 1, 4 The nurse should instruct the patient to memorize the PASS technique for safely using a fire extinguisher: pulling the pin to unlock the handle, aiming low at the base of the fire, squeezing the handle, and sweeping the unit from side to side.

The nurse is explaining and demonstrating the correct use of fire extinguishers at home to a group of adolescents. Which order of steps listed by an adolescent indicates effective learning? 1. Squeeze the handle. 2. Pull the pin to unlock the handle. 3. Aim low at the base of the fire. 4. Sweep the unit from side to side.

2, 3, 1, 4 When the nurse is explaining and demonstrating the use of fire extinguisher at home, the nurse should first pull the pin to unlock the handle. The next step is to aim low at the base of the fire. Then, the nurse then squeezes the handle and sweeps the unit from side to side.

The nurse is caring for an older adult in the home and is concerned about infection control in this patient. What should the nurse inquire about when assessing this patient's risk of food poisoning? Select all that apply. 1 Daily water intake 2 Hand-washing practices 3 Knowledge about food-storage practices 4 Monthly consumption of fruits and vegetables 5 Practice of checking expiration dates on milk products

2, 3, 5 Good hand-washing practices include washing hands before and after handling food items. Proper knowledge about food-storage practices ensures that the food consumed is safe and free of contamination. Regular practice of checking expiration dates on milk products ensures that the products are safe for consumption. Knowledge of daily water intake does not help in assessing the risk of food poisoning. Knowledge of monthly consumption of fruits and vegetables is not related to the risk of food poisoning.

Which risk factors are seen in young and middle-age adults? Select all that apply. 1 Risk of falls 2 Use of firearms 3 Substance abuse 4 Incidence of suicide 5 Inadequate nutrition

2, 3, 5 The risk factors that are seen in young and middle-age adults are use of firearms, substance abuse, and inadequate nutrition. Risk of falls is significant for older adults. Incidence of suicide is a common risk factor seen in adolescents.

A patient starts having seizures in a postoperative unit. Which measures would ensure normal breathing and reduced risk of musculoskeletal injury? Select all that apply. 1 Tighten the waist belt. 2 Loosen the collar. 3 Restrain the patient. 4 Hold the limbs loosely. 5 Place something soft under the head.

2, 4 During seizures patients may have altered breathing and may be at risk of sustaining musculoskeletal injury. Loosening the patient's collar facilitates breathing movements by reducing the effort required for chest expansion. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling it in the nurse's lap or placing a pad under the head. Limbs should be held loosely if the patient is flailing. Tightening the waist belt restricts abdominal expansion, further aggravating respirations in the patient. The patient should not be restrained during seizures, because this increases the chance of musculoskeletal injury.

A patient is experiencing unilateral neglect related to a brain injury. How can the nurse help this patient to restore normal capabilities? Select all that apply. 1 Promote the use of effective coping skills. 2 Remind the patient to scan the home environment. 3 Establish therapeutic communication. 4 Encourage family members to eat along with the patient. 5 Teach the patient to touch the affected side of the body with the unaffected hand.

2, 4, 5 A patient who has had a cerebrovascular accident may have unilateral neglect, which can increase the patient's risk for falling. The patient should be reminded to scan the home environment while walking to prevent the risk of falling. Encourage family members to eat with the patient so they can remind the patient to try to use the affected side of the mouth to eat the food. Teaching the patient to touch the affected side of the body with the unaffected hand helps the patient to become aware of the affected side. Coping skills and therapeutic communication may help the patient to cope better but are more useful for an anxious patient.

The nurse works in a psychiatric unit and understands that the use of restraints may be useful for ensuring patients' safety. Which patients would need a temporary restraint? Select all that apply. 1 Alert patients 2 Confused patients 3 Accommodating patients 4 Patients who repeatedly fall 5 Patients who try to remove medical devices

2, 4, 5 Confused patients are prone to falls and injuries, if not restrained. Patients who repeatedly fall are at an increased risk of becoming injured and should be restrained. Patients who try to remove medical devices should be restrained to prevent them from removing medical devices. Alert patients are generally cooperative and able to communicate and therefore do not require restraints. Accommodating patients are cooperative and do not require restraints.

A patient has been locked in a poorly ventilated room containing a furnace. Which condition is likely to be observed in the patient after a period of time? 1 Psychological injury 2 Orientation changes 3 Carbon monoxide poisoning 4 Decrease in core body temperature

3 A furnace, stove, or fireplace that is not properly vented introduces carbon monoxide into the environment and affects the person's oxygenation by binding with hemoglobin. A furnace in a poorly ventilated room would not lead to psychological injury. Sensory or communication impairments associated with delirium, dementia, and depression contribute to altered concentration and orientation changes. A decrease in core body temperature is observed in patients with hypothermia; the patient in this instance would be exposed to elevated temperatures, not low temperatures.

Which recommendation would be appropriate to reduce the risk of falls in a patient with hemiparesis? 1 "You should perform range-of-motion exercises." 2 "You should make use of coping skills that you have previously used." 3 "You should consult an ophthalmologist for a visual assessment." 4 "You should touch one side of your body frequently with the other hand."

3 Hemiparesis is the condition in which there is weakness on one side of the body. Consulting an ophthalmologist for visual assessment will prevent the risk of fall in a hemiparesis patient. Performing range-of-motion exercises will be helpful for a patient with impaired physical mobility. Encouraging the patient to make use of coping skills that he or she has previously used is helpful for a patient with anxiety related to falls. A patient with unilateral neglect related to brain injury will benefit from frequently touching the left side of the body with the right hand.

The nurse is instructing the mother of an infant not to leave the mesh sides of playpens lowered. Which risk can be prevented by this intervention? 1 Falls 2 Choking 3 Asphyxiation 4 Strangulation

3 If mesh sides of playpens are lowered, the possibility exists for a child's head to become wedged in the lowered mesh side and may result in asphyxiation. Falls in infants and toddlers can be prevented by instructing the mother not to leave crib sides down or babies unattended on changing tables or in infant seats. Choking can be prevented by avoiding the use of pacifiers or ribbons attached to the string around the child's neck. Strangulation can be prevented by avoiding pillows, bumper pads, large stuffed toys, or comforters in the cribs.

Which event is classified as an environmental event on the National Quality Forum list? 1 Patient death due to physical assault in the health care facility 2 Patient death due to contaminated drugs in the health care facility 3 Patient death associated with a fall during care in the health care facility 4 Patient death due to spinal manipulative therapy in the health care facility

3 Patient death associated with a fall in the health care facility is classified as an environmental event on the National Quality Forum list. Patient death due to physical assault in a health care facility is reportable under criminal events. Patient death due to contaminated drugs in a health care facility is reportable as a product or device event. Patient death due to spinal manipulative therapy in health care facility is reportable under care management events.

The nurse is teaching the parent of young child about car safety. Which statement by the parent indicates effective learning? 1 "I should secure my 6-month-old child in a forward-facing car seat." 2 "When my child is 1 year old, I can place his car safety seat in the front seat." 3 "I should place my 3-month old child in the back seat with a rear-facing convertible seat." 4 "I should not place my child in a front-facing seat before the age of 2."

3 The American Academy of Pediatrics (AAP) recommends that all infants and toddlers ride in the back seat with a rear facing only seat or rear facing convertible seat until the age of 2 or when the child reaches the highest weight or height allowed by the manufacturer of the rear-facing safety seat. A 1-year-old child should not be allowed to sit in the front seat. The child should be allowed to use a front-facing seat at the age of 2 or when the child reaches the highest weight or height allowed by the manufacturer of the rear-facing safety seat. The child can be placed in a front-facing seat before the age of 2 if the child has outgrown the rear-facing seat.

Which nursing action would be appropriate to protect a patient during a seizure? Select all that apply. 1 Using supporting pillows for the patient who is on a bed 2 Guiding the patient from the floor to the bed during the seizure 3 Turning the patient to one side, having a slightly forwarded tilted head 4 Avoiding placing any objects into the mouth when the patient's teeth are clenched 5 Placing a pad under the patient's head after guiding them to the floor from a standing position

3, 4, 5 During a seizure, the nurse should turn the patient onto one side, and the patient's head should be slightly tilted forward. When the patient's teeth are clenched, objects should not be placed into the mouth. Before positioning the patient from standing to the floor, the nurse should place a pad under the patient's head. If the patient is in bed, the surrounding pillows should be removed. When the seizure is in progress, moving the patient from the floor to the bed would be inappropriate.

Which suggestion would be appropriate to prevent unilateral neglect in a patient with hemiparesis? 1 "You should perform range-of-motion exercises." 2 "You should use a walker and cane around the home." 3 "You should consult with an ophthalmologist for visual assessment." 4 "You should touch one side of the body frequently with the other hand."

4 Hemiparesis is a condition in which there is weakness on one side of the body. A patient with unilateral neglect related to brain injury will benefit from touching the left side of the body frequently with the right hand. Performing range-of-motion exercises is helpful for patients with impaired physical mobility. Using a walker or cane around the home is helpful for patients with impaired physical mobility. Consulting an ophthalmologist for visual assessment will help prevent the risk of falls in a patient with hemiparesis.

A child in the hospital starts to have a grand mal seizure while playing in the playroom. Which is the most important nursing intervention during this situation? 1 Begin cardiopulmonary respiration. 2 Restrain the child to prevent injury. 3 Place a tongue blade over the tongue to prevent aspiration. 4 Clear the area around the child to protect the child from injury.

4 Once a seizure begins, the nurse needs to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth.

The nurse is advising the mother of a 4-month-old infant to remove plastic bags from the home. Which risk is the nurse addressing? 1 Choking 2 Poisoning 3 Head injury 4 Suffocation

4 Plastic bags from the cleaners or grocery store may cause an infant to suffocate. Choking can be prevented by avoiding the use of toys with small parts like buttons. Poisoning may occur due to toxic or poisonous substances, including plants. Head injury may be caused by falls.

Which statement is true regarding restraints? 1 Restraints are ordered prn. 2 The use of restraints involves a psychological adjustment for the family. 3 Informed consent from family members is required before using restraints. 4 Restraints are a part of the patient's prescribed medical treatment and plan of care.

4 Restraints may be a part of a patient's prescribed medical treatment and plan of care. Restraints are not ordered prn. The use of restraints involves a psychological adjustment for the patient and the family. Informed consent from family members is required before using restraints in long-term care facilities

The nurse is caring for a patient with muscle weakness. The patient is provided with skid-proof footwear. Which safety measure is implemented in this situation? 1 Enabling to remain alert 2 Promoting cooperation 3 Allowing for safe exit from bed 4 Preventing falls from slipping on floor

4 Skid-proof footwear can prevent the patient from slipping on the floor. Muscle weakness may lead to unexpected falls that can cause injuries. Skid-proof footwear can help prevent falls that are caused by slipping on the floor. Hearing aids and glasses enable patients to remain alert within their environments. Clear explanations of safety measures help elicit cooperation from the patient and family members. Providing side rails on the bed helps in the safe exit of the patient from the bed.

According to the National Quality Forum, which event is considered a care management event? 1 Abduction of a patient at any age 2 An immediate postoperative death 3 Serious disability associated with patient elopement 4 Stage III pressure ulcers acquired after admission to a health care facility

4 Stage III or IV pressure ulcers acquired after admission to a health care facility is a serious reportable care management event. The abduction of a patient at any age is a criminal event. Intraoperative or immediate postoperative death is a serious surgical event. Patient death or serious disability associated with patient elopement is a serious, reportable patient protection event.

A patient has accidently consumed kerosene. Which nursing intervention would further complicate the patient's condition? 1 Inducing vomiting 2 Maintaining the airway 3 Administering oxygen 4 Measuring oxygen saturation

1 Kerosene is a poisonous substance. Inducing vomiting in a patient who has consumed kerosene is dangerous, because it can cause aspiration. Maintaining the airway is the primary measure to reduce the risk of aspiration and is thus important in cases of kerosene poisoning. Oxygen administration is helpful in kerosene poisoning. Measuring oxygen saturation is an important intervention for this patient, because it helps to identify the need for intubation and other assistive measures.

A patient is experiencing left-sided weakness due to a cerebrovascular accident. The nurse observes that the patient fails to notice people approaching from the left side. Which nursing intervention will be most beneficial for the patient in this situation? 1 Establishing a therapeutic relationship with the patient 2 Reminding the patient to scan the entire environment when walking 3 Consulting with a physical therapist to help the patient with strengthening exercises 4 Encouraging the family to eat with the patient, and reminding the patient to eat food on left side of the plate

2 A patient who fails to notice people approaching from the left side may have unilateral neglect related to brain injury. The appropriate intervention in this case is to remind the patient to scan the entire environment when walking. Establishing a therapeutic relationship with the patient is helpful if the patient exhibits signs of anxiety related to falls or health status. Consulting with a physical therapist to help the patient with strengthening exercises will be beneficial for a patient who is at risk of falls. Encouraging the family to eat with the patient and reminding the patient to eat food on the left side of the plate is beneficial for patients who have unilateral neglect related to brain injury.

A patient was diagnosed with left-sided neglect after suffering a cerebrovascular accident. Which nursing intervention would be most effective to ensure the patient's safety? 1 Teaching the patient to use a walker 2 Reminding the patient to scan the environment while walking 3 Encouraging the patient to see an ophthalmologist for visual assessment 4 Teaching the patient to perform strengthening exercises on the left side of the body

2 The nurse should remind the patient to scan the environment when walking in the event of left-sided neglect after suffering a cerebrovascular accident, because the patient may fail to notice people or things approaching from the left. A patient with cerebrovascular accident-caused left-sided weakness should be educated regarding the use of a walker. Visiting an ophthalmologist is effective for those patients who have problems in seeing objects at a distance. The nurse should teach the patient with left sided weakness to perform strengthening exercises on the left side of the body.

A professor is teaching a group of nursing students about patient-inherent accidents. Which are examples of patient-inherent accidents in the hospital setting? Select all that apply. 1 Medication administration error 2 Improper insertion of a urinary catheter 3 Ingestion of a foreign substance 4 Pinching fingers in drawers 5 Self-inflicted cuts

3, 4, 5 Patient-inherent accidents are accidents (other than falls) caused by the patient. Examples include self-inflicted cuts, injuries, and burns; ingestion or injection of foreign substances; self-mutilation or fire setting; and pinching fingers in drawers or doors. Medication administration error and improper insertion of urinary catheter are procedure-related accidents.

The nurse is teaching a vulnerable population of patients about pollution. Which instruction should the nurse provide to help patients limit exposure to air pollution? 1 "Avoid smoking." 2 "Keep your home noise free." 3 "Avoid using bottled water." 4 "Discard the bioactive waste properly."

1 At home, school, or in the workplace, the most common cause of air pollution is smoking. Excessive noise is also a form of pollution called as noise pollution that affects the health. Bottled or boiled water should be used for drinking and cooking when there is water contamination. Improper disposal of radioactive and bioactive waste causes land pollution rather than air pollution.

The nurse is caring for an older adult in the home and is concerned about the risk of injury in this patient. Which activities should the nurse perform to assess risk of injury in this patient? Select all that apply. 1 Inspect the patient's food. 2 Perform a home hazard appraisal. 3 Inquire about the patient's visual acuity. 4 Observe the patient's posture and balance. 5 Assess the patient's gastrointestinal system.

2, 3, 4 A home hazard appraisal may reveal issues such as poor lighting, small items, or excessive furniture in the house that can increase the risk of injury. Inquiring about the patient's visual acuity helps assess the risk of falling or tripping over objects at home. Assessing the patient's posture and balance reveals any balance, coordination, or movement-related issues. Inspecting the patient's food does not help in assessment of risk. Assessing patient's gastrointestinal system does not affect the risk of injury.

The registered nurse is teaching a group of student nurses about precautions to be taken when using oxygen tanks in a hospital. Which statement made by a student nurse indicates a need for further teaching? 1 "Check the oxygen tank's tubing for kinks." 2 "Post 'No Smoking' signs in patient rooms containing oxygen tanks." 3 "Place the oxygen tanks in an upright position on the floor when not in use." 4 "Take the primary healthcare provider's advice while changing the liter flow of oxygen."

3 Oxygen tanks should be secured so they don't fall over, possibly damaging the tank. The tanks should not be placed upright on the floor when not is use; they can instead be placed flat on the floor or placed in an upright position in stands. The nurse should check for kinks in the tubing to promote the effective flow of oxygen through the tube. The contact of oxygen with heat or a spark can cause combustion. Therefore, the nurse should post "No Smoking" signs in patient rooms containing oxygen tanks. The nurse should change the liter flow of oxygen only after obtaining permission from the primary healthcare provider.

The nurse is performing fall prevention measures for a patient. During which step of the nursing process does the nurse perform "Timed Get up and Go" (TUG) if a patient is able to ambulate? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

3 Performing TUG when the patient is able to ambulate is included in the assessment step of the nursing process. Planning involves gathering equipment to promote organization and performing hand hygiene to reduce the transmissions of microorganisms. Evaluation is the basic step involved when the nurse is performing visual checks in a patient. Implementation involves adjusting the bed to a proper height and inspecting the area to prevent injuries during restraint application.

Which safety precaution performed by a parent lowers the risk of sudden infant death syndrome (SIDS) in a 1-year-old child? 1 Immunizing the infant 2 Filling crib with pillows 3 Having the infant sleep on his/her side or back 4 Attaching pacifier to string and placing it around the child's neck

3 Placing infants on their sides or backs confers the lowest risk of SIDS and it is the preferred position. Immunizing the child at an early age prevents the risk of several life-threatening complications. The parent should not fill the crib with pillows or bumper pads because these items increase the risk of suffocation or entrapment. String or ribbon around the neck increases the risk of choking.