Fundamentals of Success Safety
A nurse identifies the presence of smoke exiting the door to the dirty utility room. Place the nurse's actions in order of priority using the RACE model. 1. Pull the fire alarm. 2. Close unit doors and windows. 3. Shut the door to the utility room. 4. Provide emotional support to agitated clients.
Answer: 1, 3, 2, 4 Rationale: 1. Pulling the fire alarm ensures that appropriate hospital personnel and the fire department are notified of the fire. Trained individuals will arrive to contain and extinguish the fire and help move clients if necessary. The RACE model should be followed in a fire emergency: rescue, alarm, confine, and extinguish. The fire is in the dirty utility room, and no clients at this time need to be rescued. 2. Closing unit doors and windows provides a barrier between the clients and the fire and limits drafts that could exacerbate the fire. 3. Closing the door to the dirty utility room protects the clients and staff members in the immediate vicinity of the fire. 4. Clients should be supported emotionally during a crisis because anxiety can be contagious.
A nurse is preparing a client for a physical examination. Which is most important for the nurse to do in this situation? A. Identify the positions contraindicated for the client during the examination. B. Explore the client's attitude toward health-care providers. C. Inquire about other professionals caring for the client. D. Ask when the client last had a physical examination.
Answer: A Rationale: A. A physical examination requires a client to assume a variety of positions, such as supine, side-lying, sitting, and standing. To prevent complications, the nurse should inquire about any positions that are uncomfortable or contraindicated because of past or current medical conditions. B. Although the client's attitude toward health-care providers may be obtained before a physical examination, it is not the priority. C. Inquiring about other professionals caring for the client is not the priority before a physical examination. This might be done later to ensure continuity of care and prevent fragmentation of care. D. Although identifying when the last physical examination was performed may be done, it is not a priority before a physical examination.
A client has dysphagia. Which nursing action takes priority when feeding this client? A. Ensuring that dentures are in place B. Medicating for pain before providing meals C. Providing verbal cueing to swallow each bite D. Checking the mouth for emptying between every bite
Answer: D Rationale: A. Although this should be done if a client has dentures, it is not the priority. B. Although an analgesic may be administered, it can cause drowsiness that may increase the potential for aspiration in a client with dysphagia. C. Although this should be done, the client may be physically incapable of following this direction. D. This is the safest way to ensure that a bolus of food is not left in the mouth, where it can be aspirated and cause an airway obstruction.
Which nursing intervention enhances an older adult's sensory perception and thereby helps prevent injury when walking from the bed to the bathroom? A. Providing adequate lighting B. Raising the pitch of the voice C. Holding onto the client's arm D. Removing environmental hazards
Answer: A Rationale: A. Adequate lighting provides for the safety of clients, staff, and visitors within a hospital. Inadequate lighting causes shadows, a dark environment, and the potential for misinterpreting stimuli (illusions) and is a contributing cause of accidents in the hospital setting. This intervention maximizes a client's sense of sight. B. When talking with older adults, it is better to lower, not raise, the pitch of the voice. As people age, they are more likely to have impaired hearing with higher-pitched sounds. C. Holding the client's arm does not enhance a client's sensory perception. Holding a client's arm is not always necessary and therefore could be degrading or promote regression. D. Although this should be done, removing environmental hazards will not enhance a client's sensory perception.
A home-care nurse is assigned to care for an older adult living at home. Which is the first action the home-care nurse should employ to prevent falls by this older adult? A. Conduct a comprehensive risk assessment. B. Encourage the client to remove throw rugs in the home. C. Suggest installation of adequate lighting throughout the home. D. Discuss with the client the expected changes of aging that place one at risk.
Answer: A Rationale: A. Assessment is the first step of the nursing process. The best way to prevent falls is by identifying those at risk and instituting multiple interventions that prevent falls. B. This is inadequate. Removing throw rugs is just one strategy. C. This is inadequate. Ensuring adequate lighting is just one strategy. D. This is inadequate. Exploring the issues of aging with a client is just one strategy.
A toaster is on fire in the pantry of a hospital unit. Which should the nurse do first? A. Activate the fire alarm. B. Unplug the toaster from the wall. C. Put out the fire with an extinguisher. D. Evacuate the clients from the room next to the kitchen.
Answer: A Rationale: A. Because no client is in jeopardy, the nurse's initial action should be to activate the fire alarm. The sooner the alarm is set, the sooner professional firefighters will reach the scene of the fire. B. Unplugging the toaster is unsafe because it places the nurse in jeopardy. The nurse may be exposed to an electrical charge or become burned. C. This is an inappropriate intervention because the nurse may not be capable of containing or fighting the fire, and this action may place the nurse in jeopardy. D. Evacuating clients is premature at this time, but it may become necessary eventually.
A primary health-care provider prescribes a vest restraint for a client. Which should the nurse do first when applying this restraint? A. Perform an inspection of the client's skin where the restraint is to be placed. B. Ensure that the back of the vest is positioned on the client's back. C. Permit four fingers to slide between the client and the restraint. D. Secure the restraint to the bed frame using a slipknot.
Answer: A Rationale: A. Even when applied correctly, restraints can cause pressure and friction. A baseline assessment of the skin under the restraint should be made. In addition, the presence of a dressing, pacemaker, subcutaneous infusion port, or subclavian catheter may influence the type of restraint to use. B. Although the back of the vest should be positioned on the client's back, it is not the first intervention. C. The jacket may be too loose if four fingers are used. The jacket should be applied so that two, not four, fingers can slide between the client and the restraint. D. Securing the restraint to the bed frame using a slipknot should be done; however, it is the last, not the first, intervention associated with the application of a vest restraint.
A nurse is orienting a newly admitted client to the hospital. Which is most important for the nurse to teach the client how to do? A. Notify the nurse when help is needed. B. Get out of the bed to use the bathroom. C. Raise and lower the head and foot of the bed. D. Use the telephone system to call family members.
Answer: A Rationale: A. Explaining how to use a call bell meets safety and security needs. It reinforces that help is immediately available at a time when the client may feel physically or emotionally vulnerable in an unfamiliar environment. B. Clients generally do not need teaching about how to get out of bed to go to the bathroom. This instruction depends on the individual needs of a client. C. How to manipulate the bed is part of orienting a client to the hospital environment; however, it is not the most important point to emphasize with a client. D. Use of the telephone is part of orienting a client to the hospital environment; however, it is not the most important point to emphasize with a client.
When clinical manifestation indicates that a further nursing assessment is necessary to determine if the client is having difficulty swallowing? Select all that apply. A. Debris in the buccal cavity B. Coughing episodes C. Noisy breathing D. Slurred speech E. Drooling
Answer: A, B, C, D, E Rationale: A. Retention of food in the oral cavity indicates that the client is not swallowing ingested food completely. Food collects in the buccal cavity because the area between the teeth and cheek forms a pocket that traps food. B. When a person has difficulty swallowing, coughing episodes may occur in an effort to clear aspirated material from the respiratory tract. C. When a person has difficulty swallowing, noisy breathing may occur as secretions, food, or liquid is aspirated into the respiratory tract. D. Slurred speech reflects an inability of the tongue and muscles of the face to form words. Dysfunction of the muscles of the face and tongue will interfere with the ability to chew and swallow food. E. Drooling indicates that oral secretions are accumulating in the mouth. This may occur when a person has difficulty swallowing.
Which is an appropriately worded goal for a client who is at risk for falling? Select all that apply. A. "The client will be able to walk from a bed to a chair safely while hospitalized." B. "The client will be taught how to call for help to ambulate." C. "The client will be kept on bedrest when dizzy." D. "The client will be restrained when agitated." E. "The client will be free from trauma."
Answer: A, E Rationale: A. This is an appropriate goal. It is realistic, specific, measurable, and has a time frame. It is realistic to expect that all clients be safe. It is specific and measurable because safety from trauma can be compared with standards of care within the profession of nursing. It has a time frame because the words "while hospitalized" reflect the time frame of "continuously" while directly under the care of a health time. B. Being taught how to call for help is a planned intervention, not a goal. C. Maintaining a client on bedrest is a planned intervention, not a goal. D. This is a planned intervention, not a goal. In addition, it is inappropriate to restrain a person automatically for agitation. A restraint should be used as a last resort to prevent the client from self-injury or injuring others. E. This is an appropriate goal. It is realistic, specific, and measurable and has a time frame. It is realistic to expect that all clients be safe. It is specific and measurable because safety from trauma can be compared with standards of care within the profession of nursing. It has a time frame because the words "free from" reflect the time frame of "continuously."
A nurse is caring for a client with Parkinson's disease who is experiencing difficulty swallowing. For which major potential problem associated with dysphagia should the nurse assess the client? A. Anorexia B. Aspiration C. Self-care deficit D. Inadequate intake
Answer: B Rationale: A. Although lack of an appetite (anorexia) can occur with dysphagia, it is not the most serious associated risk. B. When a person has difficulty with swallowing (dysphagia), food or fluid can pass into the trachea and be inhaled into the lungs (aspiration), rather than swallowed down the esophagus. This can result in choking, partial or total airway obstruction, or aspiration pneumonia. C. Dysphagia is unrelated to self-care deficit. Feeding self-care deficit occurs when a person is unable to cut food, open food packages, or bring food to the mouth. D. Inadequate intake of food and fluid can result with dysphagia because of fear of choking. However, it is not the most serious associated risk.
Which is the priority nursing intervention to prevent client problems associated with latex allergies? A. Use nonlatex gloves. B. Identify persons at risk. C. Keep a latex-safe supply cart available. D. Administer an antihistamine prophylactically.
Answer: B Rationale: A. Although using nonlatex gloves may be done, it is not the priority. B. Client allergies must be identified (e.g., latex, food, and medication) before any care is provided, be documented in the client's clinical record, and appear on an allergy-alert wristband. After a risk is identified, additional safety precautions can be implemented to prevent exposure to the offending allergen. Assessment is the first step of the nursing process. C. Although keeping a latex-safe supply cart available may be done, it is not the priority. D. Administering an antihistamine is unnecessary. A person with a latex allergy should not be exposed to products with latex.
A nurse is caring for a client with a nasogastric tube for gastric decompression. Which nursing action takes priority? A. Discontinuing the wall suction when providing nursing care B. Positioning the client in the semi-Fowler position C. Instilling the tube with 30 mL of air every 2 hours D. Caring for the nares at least every 8 hours
Answer: B Rationale: A. Discontinuing the wall suction is unnecessary and can result in vomiting and aspiration. B. A nasogastric (NG) tube for gastric decompression passes down the esophagus, through the cardiac sphincter, and into the stomach. The cardiac sphincter remains slightly open because of the presence of the NG tube. The semi-Fowler position keeps gastric secretions in the stomach via gravity (preventing reflux and aspiration) and allows the gastric contents to be suctioned out by the NG tube. C. Instilling the NG tube with air is not done routinely every 2 hours. This may be done to help reestablish patency of the tube when it is clogged. D. Caring for the nares should be done more frequently than every 8 hours to prevent irritation and pressure.
A nurse is preparing a bed to receive a newly admitted client to the hospital. Which action is most important? A. Placing the client's name on the end of the bed B. Ensuring that the bed wheels are locked C. Positioning the call bell in reach D. Raising one side rail
Answer: B Rationale: A. Placing clients' names on the end of their beds violates the client's right to privacy. An identification wristband must be worn for client identification. B. Locked bed wheels are an important safety precaution. The bed must be an immovable object because the client may touch the bed for support, lean against it when getting in or out of bed, or move around when in bed. If bed wheels are unlocked during these maneuvers, the bed may move and the client can fall. C. The call bell cord may become an obstacle when moving the client into the bed. This should be done after the client is in the bed. D. The side rail may become an obstacle when moving the client into the bed. This should be done after the client is in the bed.
An unconscious client begins vomiting. In which position should the nurse place the client? A. Supine B. Side-lying C. Orthopneic D. Low-Fowler
Answer: B Rationale: A. The supine position will promote aspiration and should be avoided in this situation. B. The side-lying position prevents the tongue from falling to the back of the oropharynx, thus allowing the vomitus to flow out of the mouth by gravity and preventing aspiration. C. The orthopneic position is an unsafe, impossible position in which to maintain an unconscious client. D. The low-Fowler position will allow the tongue to fall to the back of the oropharynx, promoting aspiration. This position should be avoided in this situation.
A school nurse is teaching children about fire safety procedures. Which is the first thing they should be taught to do if their clothes catch on fire? A. Yell for help. B. Roll on the ground. C. Take their clothes off. D. Pour water on their clothes.
Answer: B Rationale: A. This eventually may be done, but the child must do something immediately before waiting for help to arrive. B. Rolling on the ground will smother the flames and put the fire out. Children should be taught to "Stop, drop, and roll." C. Taking off their clothes may be impossible. In addition, it will take time, and the clothing and skin will continue to burn. Some fabrics may adhere to the skin when they burn, and attempting to remove clothing may cause more damage to the skin. D. Finding and obtaining water will take too much time, and the clothing and skin will continue to burn. Something must be done immediately.
A male client is admitted to ambulatory care for a bilateral herniorrhaphy. A nurse on the unit interviews the client, obtains the client's vital signs, and reviews the primary health-care provider's prescriptions. Which should the nurse do first? CLIENT'S CLINICAL RECORD Primary Health-Care Provider's Prescriptions - Nothing by mouth - IVF: 0.9% sodium chloride at 125 mL/hour - Midazolam 5 mg, IM on call to preoperative suite Vital Signs - Temperature: 99.2F, orally - Pulse: 96 beats per minute - Respirations: 22 breaths per minute - Blood pressure: 124/82 mm Hg Client Interview - Client states, "I am a little nervous because I have never had surgery before." During preoperative testing, the client indicated an allergy to oxycodone/acetaminophen but forgot to include allergies to latex and peanuts. A. Contact the operating suite and inform them of the client's latex allergy. B. Ensure the client's allergy band includes the client's identified allergies. C. Notify the primary health-care provider of the client's elevated vital signs. D. Share the information about the client's anxiety with health team members.
Answer: B Rationale: A. This intervention should be performed immediately after the priority intervention. Clients with latex allergies require special precautions to be taken in the operating suite. The use of latex products can be life-threatening for the client if appropriate precautions are not taken. All equipment, such as gloves and tubes, must be latex free to protect the client from experiencing an allergy that can progress to anaphylaxis. B. Protecting the client is the priority, and a red allergy band is the first line of defense. In addition, the client's allergies must be included on other designated places on the client's medical record. C. Although the client's vital signs are on the high side of normal or slightly elevated, their elevations probably are related to the client's anxiety. These elevations should be documented and reported, but they are not the priority at this time. Normal ranges for vital signs are temperature, 97.5F to 99.5F; pulse, 60 to 100 beats per minute; respirations, 12 to 20 breaths per minute; and blood pressure: systolic pressure, less than 120 mm Hg; and diastolic pressure, less than 80 mm Hg. D. Although this should be done, this is not the priority at this time. Mild to moderate anxiety is a common response when anticipating surgery, especially when surgery is being experienced for the first time. The client's anxiety should be documented and communicated to other members of the health team, but it is not the priority at this time. However, when a client has a sense of impending doom, the surgeon should be notified immediately because the client may not be in the right frame of mind for surgery; if surgery is performed, it can be a self-fulfilling prophesy.
Which intervention should a nurse implement when assisting a client to use a bedpan? Select all that apply. A. Ensure that the bed rails are raised after the client is on the bedpan. B. Position the rounded rim of the bedpan under the client's buttocks. C. Encourage the client to help as much as possible when using the bedpan. D. Raise the head of the bed on the semi-Fowler position once the client is placed on the bedpan. E. Dust talcum powder on the rim of the bedpan before placing the bedpan under the client.
Answer: B, C, D Rationale: A. Client safety is a priority. A bedpan is not a stable base of support, and the effort of elimination may require movements that alter balance. Side rails provide a solid object to hold while balancing on the bedpan and supply a barrier to prevent falling out of bed. B. The rounded rim of a bedpan should be placed under the client's buttocks because the rounded rim supports the client's weight when sitting on the bedpan. C. Encouraging the client to help promotes the client's independence and limits strain on the nurse. D. The semi-Fowler position is comfortable and provides a more normal position for defecation that helps prevent straining. E. The use of talcum powder should be avoided because it is a respiratory irritant.
Which human response to illness alerts the nurse that a client is at risk for aspiration during meals? Select all that apply. A. Bulimia B. Lethargy C. Anorexia D. Stomatitis E. Dysphagia
Answer: B, D, E Rationale: A. The risk for aspiration in a client with bulimia occurs after, not during, meals. Bulimia is characterized by episodes of binge eating followed by purging, depression, and self-deprecation. B. When a person is sleepy, sluggish, or stuporous (lethargic), there may be a reduced level of consciousness and diminished reflexes, including the gag and swallowing reflexes. This condition can result in aspiration of food or fluids that can compromise the person's airway and respiratory status. C. A lack of appetite (anorexia) is unrelated to aspiration. The less food or fluid that is placed in the mouth, the less the risk is for aspiration. D. An inflammation of the mucous membranes of the mouth (stomatitis) may result in dysphagia and increase the risk of aspiration. E. Dysphasia (difficulty swallowing) places a client at risk for aspiration generally because of impaired innervation of the tongue and muscles used for swallowing.
A nurse is planning care for a client who requires bilateral arm restrains because the client is delirious and attempting to pull out a urinary retention catheter. Which information is important to consider when planning care for this client? Select all that apply. A. Use of restraints adequately prevents injuries. B. Reasons for use of restraints must be clearly documented. C. Most clients recognize that restraints contribute to their safety. D. Restraints need a health-care provider's prescription before application. E. Laws permit the use of restraints when specific guidelines are followed.
Answer: B, E Rationale: A. This statement is not true. Injuries and falls can occur if restraints are not applied appropriately. In addition, research indicates that clients incur less severe injuries if they are left unrestrained. B. The reason for the use of restraints must adhere to standards of care and be documented on the client's clinical record to create a legal document that protects the client as well as health-care providers. C. The opposite is true. Clients resist the use of restraints and usually are mentally or emotionally incompetent to understand their necessity or benefits. D. Restraints can be applied by nurses in emergencies without a primary health-care provider's prescription to protect clients from harming themselves or others. Restraints can be used for nonviolent clients who are at risk for harming themselves (level 1 restraint) or violent clients who are at risk for harming themselves or others (level 2 restraint). A primary health-care provider must assess the client and document the need for the original application of the restraint and its continued use within specified time frames. Foe example, for a level 1 restraint, a primary health-care provider's prescription must be obtained within 12 hours after its application and daily thereafter, whereas for a level 2 restraint, a primary health-care provider must evaluate the client within 1 hour after its application and every 4 hours thereafter. E. Federal and state laws provide specific guidelines regarding clients' rights and responsibilities of caregivers associated with the use of restraints. In addition, The Joint Commission has specific guidelines that require documentation of the following: previous restraint-free interventions that have failed to prevent the client; a description of the situation indicating a need for the restraint; the least restrictive restraint that has been selected; and assessments and prescriptions by a primary health-care provider within specific time frames.
A 3-year-old child is admitted to the pediatric unit. Which should the nurse to do maintain the safety of this preschool-age child? A. Teach the child how to use the call bell. B. Put the child in a crib with high side rails. C. Ensure the child is under continuous supervision. D. Have the child stay in the playroom most of the day.
Answer: C Rationale: A. A preschool-age child does not have the cognitive and emotional maturity to use a call bell. B. A preschool-age child might attempt to climb over the side rails. A crib with high side rails is more appropriate for an infant. C. Constant supervision ensures that an adult can monitor the preschool-age child's activity and environment so that safety needs are met. Preschool-age children are active, curious, and fearless and have immature musculoskeletal and neurological systems, narrow life experiences, and a limited ability to understand cause and effect. All of these factors place preschool-age children at risk for injury unless supervised. D. This is inappropriate because most preschoolers still take one or two naps daily, the child may be on bedrest, and periods of activity and rest should be alternated to conserve the child's energy.
A nurse is assessing a client who is being admitted to the hospital. Which is the most important information that indicates whether the client is at risk for physical injury? A. Weakness experienced during a prior admission B. Medication that increases intestinal motility C. Two recent falls that occurred at home D. The need for corrective eyeglasses
Answer: C Rationale: A. Although this is important information, it is not the most important factor of the options presented in this question. In addition, the prior admission may have been too long ago to have any current relevance. B. A client with increased intestinal motility may experience diarrhea, which may place the client at risk for a fluid and electrolyte imbalance, not a physical injury. Although a person with diarrhea may need to use the toilet more frequently, a bedside commode or bedpan can be used to reduce the risk of falls. C. This is significant information that must be considered because if falls occurred before, then they are likely to occur again. When a risk is identified, additional injury prevention precautions can be implemented. D. Although this is important information, it is not the most important factor of the options presented in this question.
The risk management coordinator is preparing a program on the factors that contribute to falls in a hospital setting. Which factor that most often contributes to falls should be included in this program? A. Wet floors B. Frequent seizures C. Advanced age of clients D. Misuse of equipment by nurses
Answer: C Rationale: A. Although wet floors can contribute to falls, they are not the most common factor that contributes to falls in the hospital setting. B. Although seizures can contribute to falls, most clients do not experience seizures. C. Older adults who are hospitalized frequently have multiple health problems, are frail, and lack stamina. All of these factors contribute to the inability to maintain balance and ambulate safely. D. Although this occasionally happens and is negligence, it is not the most common factor that contributes to falls in the hospital setting.
Which is the last step in making an occupied bed that the nurse should teach a nursing assistant? A. Elevating the head of the bed to a semi-Fowler position B. Ensuring that the client is in a comfortable position C. Lowering the height of the bed toward the floor D. Raising both the upper side rails on the bed
Answer: C Rationale: A. Elevating the head of the bed may not be necessary. This action should be based on the individual needs of the client. B. Assisting the client to a comfortable position should be done while the bed is at an effective working height for the caregiver. C. It is safer if the bed is in the lowest position because a higher risk for injury to a client occurs when the mattress of the bed is farther from the floor. D. Raising the upper side rails on the bed may not be necessary. This action should be based on the individual needs of the client.
A nurse is planning care for a client with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range? A. Once a shift B. Once an hour C. Every 2 hours D. Every 4 hours
Answer: C Rationale: A. Once a shift is too long a period; it promotes the development of injuries (e.g., contractures, pressure ulcers). B. Once an hour generally is too often and unnecessary. C. Restrains should be removed every 2 hours. The extremities must be moved through their full range of motion to prevent muscle shortening and contractures. The area must be massaged to promote circulation and prevent pressure injuries. D. Four hours is too long a period between activities and promotes the development of injuries.
Profuse smoke is coming out of the heating unit in a client's room. Which should the nurse do first? A. Open the window. B. Activate the fire alarm. C. Move the client out of the room. D. Close the door to the client's room.
Answer: C Rationale: A. Opening a window is contraindicated because environmental air will feed the fire and cause it to increase in severity. B. Although activating the alarm will be done, it is not the priority at this point in time. C. The client's physical safety is the priority. The client must be removed from direct danger before the alarm is activated and the fire contained. D. Although closing the door will be done eventually, it is not the priority at this point in time.
Which should the nurse do to best prevent a client from falling? A. Provide a cane. B. Keep walkways clear of obstacles. C. Assist the client with ambulation. D. Encourage the client to use hallway handrails.
Answer: C Rationale: A. The client may or may not need a cane. An unnecessary cane may actually increase the risk of a fall. B. Although this should be done, it is not the best intervention of the options presented. C. This widens the client's base of support, which improves balance and decreases the risk of a fall. D. Although this should be done, it is not the best intervention of the options presented.
A nurse is caring for a confused client. Which should the nurse do to prevent this client from falling? A. Encourage the client to use the corridor handrails. B. Place the client in a room near the nurses' station. C. Reinforce how to use the call bell. D. Maintain close supervision.
Answer: D Rationale: A. A confused client may not be able to follow directions or understand how to use corridor handrails. B. Moving the client near the nurses' station may be impossible and impractical. C. A confused client may not be able to follow directions or understand how to use a call bell. D. Maintaining safety of the confused client is best accomplished through close or direct supervision. Confused clients cannot be left on their own because they may not have the cognitive ability to understand cause and effect, and therefore their actions can result in harm.
A nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized client should they be taught is at the highest risk for injury? A. School-age child B. Comatose teenager C. Postmenopausal woman D. Confused middle-age man
Answer: D Rationale: A. Although a school-age child is at risk for injury in a hospital setting, age-related precautions always are instituted. More nurses generally are assigned to pediatric units, and family members are frequently at the bedside. B. A client in a comma is not at as high a risk for injury as a client in another option. A client in a coma demonstrates less response to painful stimuli, generally has an absence of muscle tone and reflexes in the extremities, and appears to be in a deep sleep. C. A woman after menopause is not at a high risk for injury. D. A confused client is at an increased risk for injury because of the inability to comprehend cause and effect; therefore, such a client lacks the ability to make safe decisions.
A nurse must apply a hospital gown that does not have snaps on the shoulders to a client receiving an IV infusion in the forearm. Which should the nurse do? A. Put the gown on the client's arm without the IV, drape the gown over the other shoulder, and adjust the closure behind the neck. B. Close the clamp on the IV tubing for no more than 15 seconds while putting the gown on the client. C. Disconnect the client's IV at the insertion site, apply the gown, and then reconnect the IV. D. Insert the client's IV bag and tubing through the sleeve from inside of the gown first.
Answer: D Rationale: A. Draping the gown over the shoulder leaves the client exposed unnecessarily. It interferes with privacy, and the client may feel cold. B. Stopping the flow of the IV solution can result in blood coagulating at the end of the catheter in the vein, compromising the patency of the IV tubing. C. Disconnecting the IV tubing at the catheter insertion site is unnecessary. This increases the risk of contaminating the equipment and the potential for infection. D. Inserting the IV bag and tubing through the sleeve from inside of the gown first ensures that the IV bag and tubing are safely passed through the armhole of the gown before the client puts the arm with the insertion site through the gown. This prevents tension on the tubing and insertion site, which limits the possibility of the catheter dislodging from the vein.
A family member brings an electric radio to a client in a long-term care facility. The client tells the nurse that an electric shock was felt while turning on the radio. Which should the nurse do first? A. Arrange for the maintenance department to examine the radio. B. Disconnect the radio from the source of energy. C. Check the client's skin for electrical burns. D. Take the client's apical pulse.
Answer: D Rationale: A. Having the radio examined may be done eventually; it is not the priority at this time. B. Disconnecting the radio is contraindicated because it may place the nurse in jeopardy. C. Inspect the client's skin is not the priority, and electrical burns may or may not be evident. D. An electrical shock can interfere with the electrical conduction system within the heart and result in dysrhythmias. An electrical shock can be transmitted through the body because body fluids (consisting of sodium chloride) are an excellent conductor of electricity.
A nurse in the nursing education department of a community hospital is planning an inservice education class about injury prevention. Which factor that most commonly causes physical injuries in hospitalized clients should be included in the teaching plan? A. Malfunctioning equipment B. Failure to use restraints C. Visitors D. Falls
Answer: D Rationale: A. Malfunctioning equipment is not a common cause of injuries in a hospital. B. The use of restraints has declined dramatically, and now they are used only when clients may harm themselves or others. C. Visitors are not the main cause of injuries in a hospital. D. Research demonstrates that most physical injuries experienced by hospitalized clients occur from falls. Failing to call for assistance, inadequate lighting, and the altered health status of clients all contribute to falls.
A nurse is caring for a client with dementia. Which time of day is of most concern for the nurse when trying to protect this client from injury? A. Afternoon B. Morning C. Evening D. Night
Answer: D Rationale: A. The sunlight and usual afternoon activities generally help keep clients with dementia more oriented and safe. B. The sunlight and the routine morning activities of hygiene, grooming, dressing, and eating generally help keep clients with dementia more oriented and safe. C. As the day progresses and the sun sets, the concern for safety increases because of altered cognition (sundowner syndrome). However, in the evening there are activities of daily living and available caregivers to distract the client and provide for safety. D. At night, clients with dementia often continue to experience confusion and agitation. At night there is less light, less activity, and fewer caregivers, so there are fewer orienting stimuli. Clients who are confused or agitated are at an increased risk for injury because they may not comprehend cause and effect and therefore lack the ability to make safe judgments.
Which action is important when the nurse uses a stretcher? Select all that apply. A. Raising the bed above the level of the stretcher when transferring a client from the stretcher to a bed B. Guiding the stretcher around a turn by leading with the end with the client's head C. Ensuring that the client's head is at the end with the swivel wheels D. Pulling the stretcher on the elevator with the client's feet first E. Pushing the stretcher from the end with the client's head
Answer: E Rationale: A. Keeping a bed lower, not higher, than a stretcher when transferring a client from the stretcher to a bed uses gravity, which places less stress and strain on both the client and nurses. B. It is too difficult and unsafe to maneuver a stretcher with the nonswivel wheels on the leading end of the stretcher. The end of the stretcher with the client's head does not have swivel wheels. C. The swivel-wheeled end of the stretcher should be the leading end of the stretcher, and it is unsafe to lead with the client's head. In addition, the end of the stretcher with the swivel wheels moves through greater arcs; this can cause dizziness. The swivel wheels of a stretcher should be at the end under the client's feet, not the head. D. This is unsafe and places the client in physical jeopardy. The elevator doors may inadvertently close by the client's head while the nurse is pulling the feet end of the stretcher into the elevator. The client should be moved into an elevator head, not feet, first. E. A stretcher should always be pushed form the end of the stretcher with the client's head so that the client's head is protected. The swivel wheels must be under the client's feet on the leading end of the stretcher for safe maneuverability.
