Fundamentals of Nursing III (Chap 26 Safety, Security, Emergency Preparedness Prep U)

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." A paramount fire-safety issue is smoke detectors, since approximately half of home fire deaths occur in a home without a smoke detector

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention?

"Only certain members of the healthcare team can extinguish a fire." All members of the healthcare team are educated about how to extinguish a fire. Therefore, the UAP's statement about certain members being taught how to use the fire extinguisher requires correction

What statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 9-month-old infant?

"We place our baby in a rear-facing car seat in the back seat of the car." The American Academy of Pediatrics recommends that all children from birth to 2 years of age remain in a rear-facing car seat in the back seat of the car until they are 2 years, or until they reach the maximum height and weight for the car seat.

The nurse is caring for four clients. Which does the nurse anticipate may have a latex sensitivity?

21-year old who cannot eat bananas. The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes. The nurse will anticipate that the client who cannot eat bananas may have a latex sensitivity

A 14-year-old boy is in the clinic for his well-child exam. When the client asks his mother if she has any questions for the practitioner, she states "He sleeps so much. I am worried about how lazy he is." What does the nurse know to be true about sleep in adolescents?

Adolescence is a time of rapid physical growth and more sleep is required. Many adolescents try to balance afterschool activities with jobs and school, resulting in sleep deprivation

An 18-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

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

A school nurse is teaching a group of adolescents about safe driving. What behaviors should the nurse encourage in order to help prevent motor vehicle accidents? (Select all that apply.)

Always wear a seat belt. Limit the number of other adolescents in the car. Never text while driving. Obey the speed limit.

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client?

An older adult with multiple driving infractions may be having difficulty with sensory-perceptual alterations due to aging changes such as glaucoma, cataracts, presbyopia, presbycusis, cognition, or response time impairments

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?

An unintentional injury or incident that compromises safety in a health care agency requires the completion of a safety event report (incident report). The nurse completes the event report immediately after the incident and is responsible for recording the circumstances and the effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation.

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

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 caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed, despite instructions to remain there. Which initial intervention is appropriate?

Assess for the need to urinate.

A school-aged child is admitted to the Emergency Room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the patient?

Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation. Therefore, assessment of vital signs and respiratory status is a priority for this client

Which topics should be included in an education plan for preventing falls in the home? Select all that apply.

Avoid climbing on a chair or table to reach items that are too high. Use a nightlight. Remove clutter from walkways. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat.

What is the most appropriate outcome for the client that has a nursing diagnosis of "Risk for injury related to the use of assistive mobility devices in an unfamiliar environment?"

Because this client has been assigned a nursing diagnosis of "Risk for injury related to the use of assistive mobility devices in an unfamiliar environment," the nurse should determine that the client is at risk for falls and, therefore, a good outcome would be to prevent falls.

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?

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 telehealth nurse receives a call from a caller who states that upon entering the home, two confused family members have been found 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?

Carbon monoxide (CO) is extremely lethal because it is colorless, odorless, and tasteless. The nurse recognizes symptoms of bright cherry red skin color, nausea, headache, and inability to move. The initial direction will be for the caller to open doors and windows to reduce the level of toxic gas and provide adequate ventilation

A nurse is applying restraints to a confused client who has threatened the safety of a roommate. Which actions would the nurse perform when properly applying restraints to a client? Select all that apply.

Check agency policy for the application of restraints and secure a physician's order. Pad bony prominences. Remove the restraint at least every 2 hours or according to agency policy and client need.

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

Chemical restraints are medications, such as an antipsychotic, that are used to manage a client's behavior or freedom of movement. These are generally used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the client, staff, or others

A child is playing soccer and is involved in a head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? (Select all that apply.)

Concussions are a frequently seen sports injury in school age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present. Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual

A team of inner city school nurses attends a community conference on child safety during the summer months. What would be the priority health outcome that these nurses would expect to achieve in summer school?

Educating school-age children about safety when playing sports and other physical activities is an important responsibility of school nurses

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

Fire safety

An anxious son asks the nurse how he can keep his older adult father safe in his home. He tells the nurse that his father lives alone, has chronic illnesses, and also has sensory-perceptual alterations. What is the best statement by the nurse?

Helping older clients dispense the correct dose of medication at the correct time is important to maintaining their homeostasis, prevents possible adverse effects, and/or dangerous drug interactions

The nurse is teaching the caregiver of a 3-year old about safety. Which teaching will the nurse include?

Household chemicals, which are associated with a risk for poisoning, should be placed out of the toddler's reach

The nurse is teaching a nursing student about proper latex glove use. Which teaching will the nurse include?

If latex gloves are used, nurses should wash hands thoroughly after removing gloves with a pH balanced soap. They should use powder-free, not powdered, gloves. They should not snap gloves when applying them. They should avoid using oil-based hand creams or lotions.

One of the leading causes of death in the United States, particularly in southwestern states, is drowning. How can the nurse assist in lowering this statistic?

Implement drowning-prevention strategies.

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

Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Therefore, the nurse teaches the caregiver to supervise the child on the changing table

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 is caused by bombs and other explosives that are used to inflict mass trauma and cause multiple fatalities. Bioterrorism involves the deliberate spread of pathogenic organisms into the community. Chemical terrorism involves the deliberate release of a chemical compound for the purpose of causing mass destruction. Nuclear terrorism involves the dispersal of radioactive materials into the environment for the purpose of causing injury and death.

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?

National Patient Safety Goals require that two methods for identification (e.g., the client's name and date of birth) be confirmed prior to administration of medications or treatments

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply.

Nurses should be stewards of a safe environment. In order to promote safety and prevent injuries nurses must be aware of factors that impact the safety of clients. Some of those factors include the client's developmental level, lifestyle, mobility, sensory perception, knowledge level, communication ability, physical health state, and psychosocial state.

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?

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

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords.

The nurse on a medical surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. Which of the following should be the nurse's first action?

Remove the client from the room.

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.

Owen is a 15-year-old client who is waking up postoperatively. He became combative and tried to strangle one of the nurses. A support team was called and 4-point restraints were applied in this emergent situation. How soon does a licensed provider need to assess the client and place the restraint order?

Restraints can be placed emergently without the order of a licensed provider. However, a face-to-face assessment of the client must be made within 1 hour of restraint placement.

A nurse is caring for an 18 month-old boy status post a tracheostomy. He is recovering well and wanting to be more active. The nurse selects a toy from the playroom for him to play with. Which toy is most developmentally appropriate?

Rocking horses are a great toy for development of leg muscles.

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk?

She may be the victim of cyber-bullying. Symptoms of cyber-bullying include faltering school achievement, absenteeism, health concerns, isolating oneself from peers/friends, and increased anxiety and depression symptoms

The nurse begins a shift and finds that the wrong medication has been administered to a client. After completing a safety event report, what should the nurse do next?

Submit the safety report to the appropriate department within the facility so that it can be reviewed.

A nurse follows the universal patient compact principles for partnership when providing care for patients. Which nursing action does not reflect this philosophy?

The National Patient Safety Foundation's Principles for Partnership represent a concerted effort to demonstrate a health care organization's commitment to respect the rights of patients and incorporate these beliefs into their mission. The nurse making decisions for an uncooperative patient does not demonstrate these principles

The nurse is caring for a client with Alzheimer's disease. A family member states, "I am afraid I will go to bed one night, and the next morning my loved one will be missing from wandering off." What is the appropriate nursing response?

The appropriate nursing response is to refer the client's family member to a program such as the Alzheimer's Association's "Safe Return" program. This validates the family member's concern, and provides a resource

The nurse needs to plan the interventions necessary to reduce fall risks for the older adult clients at her facility. Which is the strongest indicator that a client is at risk for falls?

The client has fallen before. Documentation that a client has sustained previous falls is a strong predictor of a risk for future falls

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

The leading cause of injury and death in children 1 to 4 years of age is drowning. Therefore, providing close supervision when children are in or around tubs and pools will help decrease and/or prevent this injury.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

The nurse completes the safety event report immediately after an unintentional injury and is responsible for recording the incident and its effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation.

What is the primary role of the nurse in the care of clients that experience domestic violence?

The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment

The unlicensed personnel tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

The nurse should attempt to prevent the client confused client from getting out of bed by themselves to prevent a fall using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all 4 siderails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort when the client is in danger of harming themselves or others.

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

The nurse should determine that additional information is needed when the participant states that the chin strap should fit two fingers underneath. The chin strap needs to be snug, and the ability to fit two fingers indicates it is not snug enough

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish

An older adult client is planning to move with her son and daughter-in-law into a bigger apartment. The son asks the nurse for some tips to keep his mother safe. What would the nurse most likely include?

The nurse should suggest that the client put nightlights in the hallway or stairway to illuminate the area during the night

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

The parents should not leave the toddler for an unattended bath.

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

The whole family should regularly practice a fire escape plan, such as crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire

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?

Unintentional injuries are the fifth leading cause of deaths behind heart disease, cancer, stroke, and chronic obstructive lung disease

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

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 Older adults often wear slippers to accommodate swollen feet. Although slippers are more comfortable, less expensive, and less tiring to put on than shoes, they do not offer much support or traction. The nurse should intervene to remind the UAP that better footwear should be utilized.

The nurse overhears an older client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

In 90% of elder abuse cases that are reported, the person doing the abusing is a family member. The best thing to do would be for the nurse to get the client alone so that she can discuss the relationship that was observed.

What best describes the nurse's role in disaster preparedness?

Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources.

An 8-year-old boy fell off his bicycle. He was not wearing a helmet and has sustained a concussion. What information should the nurse teach the parents about concussions?

"It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness."

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?

"Parents are effective role models for children when they also wear helmets while riding."

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation, rather than burns

Which assessment finding when screening a family with an 11-month-old infant in that is beginning to pull to stand should be most concerning?

As infants begin to become mobile and more active, they have the tendency to pull up on objects and climb on furniture because they are curious. Since this 11-month-old is becoming mobile and is pulling up, the risk is great that he may pull over a cup of the mother's hot coffee that she drinks all day

The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function.

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

Medication overdoses are among the more common sources of poisoning in older adults, a phenomenon that can be reduced by ensuring that medications are in clearly labeled containers to avoid administration errors

The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include:

Older adults have significant risk of falls at home, due to aging changes such as diminished cognition, vision, hearing, and balance. Multiple medications, especially those altering level of consciousness, and household objects that challenge safe mobility, are common dangers

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 task risks. Adolescents tend to be impulsive and take risks as a result of peer pressure, so this is important for the nurse to teach the adolescent.

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?

Risk for poisoning related to poor eyesight and the inability to read medication labels