Fun Ch. 28

A nurse visits an older adult client at home and assesses the safety of the client's environment. Multiple small rugs are located in the home. Which statement by the nurse is appropriate when addressing the client's safety?

"I am concerned that the small rugs in your home can be a tripping hazard."

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states:

"I should be able to fit two fingers between my chin and the chin strap."

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important?

"Make sure that you have smoke detectors in your house and that they're in working order."

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

"Use the call bell for any needs and wear nonslip footwear."

The nurse is discussing car safety with the parents of a 5-year-old child. The parents question the need for the use of special car seats for their child. What information should the nurse provide?

"Your child should likely be using a booster seat."

The facility is conducting an educational seminar for newly employed nurses. The program addresses the reporting of sentinel events. Which occurrences qualify for this criteria? Select all that apply.

-A client's infant is misidentified and receives breast milk from another mother. -A client faints during ambulation with the nurse, resulting in a concussion. -The nurse administers a lethal dosage of medication in error.

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply.

-A person with a history of falls is likely to fall again. -Some people are more at risk for accidents than others. -A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply.

-Obtain order from a licensed provider within minutes of restraint application. -Check circulation and skin condition every 2 hours. -Offer regular, frequent opportunities for toileting.

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 completing a situational assessment. Which findings would cause the nurse concern? Select all that apply.

-The client is wearing the oxygen around the neck. -There is spilled water on the floor. -The IV is not infusing at the correct rate. -The skin is a bluish-color.

A client's surgical wound dehisced when a nurse removed the staples before a health care provider prescription was given. Following root cause analysis, which organizational response(s) is appropriate? Select all that apply.

-The nurse will be found to have committed a human error. -Systems around the documentation of prescriptions will be reviewed.

A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply.

-Use filtering software to block objectionable information. -Investigate any public chat rooms used by the children. -Be alert for downloaded files with suffixes that indicate images or pictures.

An older adult client in the hospital has been deemed a risk for falls. What falls prevention measure should the nurse prioritize?

Anticipate the client's need to urinate, and assist to the toilet as appropriate.

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse?

Arrange for a skilled home care assessment

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?

Conceal IV tubing with gauze wrap

The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize?

Establish the nurse's role during a disaster

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

Extremity restraint

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death?

Fifth

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints?

Investigate the possibility of discontinuing his or her catheter.

A nurse working in a long-term care facility is instituting interventions to prevent falls. Which intervention is an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?

Involve family members in the client's care.

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide?

Open doors and windows.

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include?

Peer pressure causes children of this age to take risks.

What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn in the household?

Position the newborn on their back for sleep.

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls?

Provide a bedside commode and ensure adequate lighting.

A nurse is completing an intake assessment. The nurse notes that an older adult client appears to have bruises in varying stages of healing. Which action should the nurse take first?

Question the client about the source of the bruises.

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

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation?

Rescue anyone who is in immediate danger.

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident.

The nurse uses the QSEN competency of Informatics when planning care for clients. What is an example of the use of this skill?

The nurse researches new technological advances in the treatment of cancer.

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety?

administering medications to the client

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include?

appropriate positioning for sleeping

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

identifying systemic factors on the unit that may have contributed to the event

The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate?

identifies client's full name and date of birth

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of:

mass trauma terrorism.

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls?

provides slippers for ambulation