Funds P.u. chp 27 Safety, Security, and Emergency Preparedness

Which factor is related to the highest proportion of falls in long-term care settings? A. Agitation B. Impaired sleep patterns C. Polypharmacy D. Toileting

D. Toileting Explanation: More than 42% of falls in an acute care agency were toileting related, often involving getting out of bed or ambulating to the bathroom, slipping from the toilet or commode, or standing to use the urinal. This exceeds the role of other variables, including agitation, polypharmacy and impaired sleep. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 775-778. Chapter 27: Safety, Security, and Emergency Preparedness - Page 775-778

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. A. Admits to drinking wine through the evening B. Has history of diabetic neuropathy C. Shares a one floor living space with a spouse D. Takes furosemide daily E. Participates in a walking club

A. Admits to drinking wine through the evening B. Has history of diabetic neuropathy D. Takes furosemide daily The acronym DAME (Drug/alcohol use, Age-related physiologic status, Medical problems, Environmental) assists the nurse to asses fall risk at home. The diuretic furosemide may cause the client to fall during frequent and possibly urgent trips to the toilet. Furosemide may also cause volume depletion and dizziness in standing. Diabetic neuropathy contributes to falls because of loss of normal sensation in feet and lower extremities. Consuming alcohol contributes to loss of balance, volume depletion and urinary urgency. Living on one floor and performing regular exercise describe positive characteristics for fall prevention. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 757-759. Chapter 27: Safety, Security, and Emergency Preparedness - Page 757-759

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate? A. Assess for the need to urinate. B. Raise the side rails. C. Contact the health care provider for a prescription to apply a waist restraint. D. Administer a prescribed dose of lorazepam.

A. Assess for the need to urinate. Explanation: Client needs should be assessed before considering physical or pharmacologic restraint. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 774-775. Chapter 27: Safety, Security, and Emergency Preparedness - Page 774-775

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic? A. Begin swim lessons with toddlers. B. Implement drowning prevention strategies. C. Require fencing around all pools. D. Educate children in cardiopulmonary resuscitation.

B. Implement drowning prevention strategies. Explanation: The principles of injury control have interventions centered at three primary levels: the individual level--providing education about safety hazards and prevention strategies; the design phase--using engineering and environmental controls; and the regulatory level--creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users. Although the nurse's role would fit into the individual level of providing education, it is not the nurse's responsibility to teach cardiopulmonary resuscitation or swimming in this scenario. As the nurse's role does not include the design phase or regulatory level, it is not a nursing responsibility to require fencing around all pools. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 766. Chapter 27: Safety, Security, and Emergency Preparedness - Page 766

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? a. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. b. Individualize the use of restraints and choose the most easily used device. c.Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others. d. Respond to the past history of the client (including previous falls) to determine the need for restraints.

C. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others. The client should be released from the restraint as soon as he or she is no longer a risk to self or others. Decisions should be based on the client's present status, not on his or her history. Restraints must be ordered by a health care provider and the least restrictive device should be used. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 786-789. Chapter 27: Safety, Security, and Emergency Preparedness - Page 786-789

The nurse overhears an older adult 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? a. Ask to examine the client alone in order to speak to her privately. b. Document the observed behaviors in the client's chart. c. Report the suspicions to to the authorities. d. Nothing, as it is none of the nurse's concern.

a. Ask to examine the client alone in order to speak to her privately. 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. Documenting the behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury to the client. The nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 755. Chapter 27: Safety, Security, and Emergency Preparedness - Page 755

A 5-year-old is admitted to the ICU after a head trauma from a bike injury. The child is awake but confused and continues to pull at IV tubing and a catheter. When the provider orders a restraint, what options would be least restrictive? Select all that apply. a. four side rails up b. having a parent stay with the child c. isolation d. administration of sedation e. four-point soft restraints

a. four side rails up b. having a parent stay with the child d. administration of sedation The use of four-point restraints and isolation would likely increase agitation. These would be appropriate if behavior was violent or if behavior posed an immediate threat to self or others, such as trying to climb out of the bed. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 774. Chapter 27: Safety, Security, and Emergency Preparedness - Page 774

What national organization determined that unintentional injuries were the fifth-leading cause of all deaths in the United States? a. World Health Organization b. Centers for Disease Control and Prevention c. American Medical Association d. American Nurses Association

b. Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) and the National Safety Council determined that unintentional injuries were the fifth-leading cause of all deaths in the United States in 2009. The American Medical Association and American Nurses Association do not monitor such data. The World Health Organization focuses on global issues and events. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 757-782. Chapter 27: Safety, Security, and Emergency Preparedness - Page 757-782

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care? a. Flush the eyes with a cool saline solution for a 10-minute period. b. Flush the eyes with water for 10 minutes. c. Wash the eyes with a hypertonic solution for at least 30 minutes. d. Advise the client to avoid blinking until after the eyes are irrigated.

b. Flush the eyes with water for 10 minutes. If poisonous substances have been instilled into the eye, immediate irrigation with lukewarm water for 10 to 15 minutes may reduce harmful effects. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 780. Chapter 27: Safety, Security, and Emergency Preparedness - Page 780

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? a. The nurse adds the information in the safety event report to the client health record. b. The nurse details the client's response and the examination and treatment of the client after the incident. c. The nurse provides an opinion of the physical and mental condition of the client that may have precipitated the incident. d. The nurse calls the primary health care provider to fill out and sign the safety event report.

b. The nurse details the client's response and the examination and treatment of the client after the incident. 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. The physician is not responsible for filling out or signing the safety report unless she witnessed the incident. The nurse reports factual information, not opinions. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 791. Chapter 27: Safety, Security, and Emergency Preparedness - Page 791

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. A geriatric chair with a tray b. a dose of antipsychotic c. a dose of analgesic d. side rails

b. a dose of antipsychotic Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 775. Chapter 27: Safety, Security, and Emergency Preparedness - Page 775

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? a. Waist restraint b. Mummy restraint c. Extremity restraint d. Elbow restraint

c. Extremity restraint The extremity restraint is appropriate during an accidental removal of therapeutic devices because it provides short-term restraint designed to control all movement. The vest restraint, mummy restraint, and elbow restraint are not appropriate in this situation. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 786-789. Chapter 27: Safety, Security, and Emergency Preparedness - Page 786-789

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse? a. Perform a vision test with Snellen chart b. Assess the client for signs and symptoms of osteoporosis c. Arrange an audiology consult to evaluate hearing d. Arrange for a skilled home care assessment

d. Arrange for a skilled home care assessment The client's home should be evaluated for potential hazards and risks. There is no indication of vision or hearing issues. It is uncommon for falls to be directly attributable to osteoporosis. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 757-758. Chapter 27: Safety, Security, and Emergency Preparedness - Page 757-758

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate? a. The report becomes a confidential part of the client's health record once it is reviewed by hospital administration. b. The incident report is reviewed by state agencies and the Occupational Safety and Health Administration rather than by hospital administration. c. The client and the client's family will be required to sign the report, acknowledging that they read it before it was filed. d. The report provides a detailed and objective account of the circumstances before, during, and after the event.

d. The report provides a detailed and objective account of the circumstances before, during, and after the event. Incident reports are used for internal review and improvements to systems. They include detailed descriptions of the event in question. They do not become part of the client's health record. They are often provided to outside agencies, but they do not bypass the institution where the event occurred. Clients and their families do not sign incident reports. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 778. Chapter 27: Safety, Security, and Emergency Preparedness - Page 778

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply. a. Drowsiness b. Vomiting c. Increased thirst d. Headache e. Fever

a. Drowsiness b. Vomiting d. Headache 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. Fever and increased thirst are not symptoms usually seen with a concussion. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 768. Chapter 27: Safety, Security, and Emergency Preparedness - Page 768

A nurse is teaching parents about Internet safety for children. Which actions are recommended guidelines for Internet use? Select all that apply. a. Investigate any public chat rooms used by the children. b. Use filtering software to block objectionable information. c. Emphasize that everything read online is usually true. d. Keep identifying information posted on the web sites. e. Be alert for downloaded files with suffixes that indicate images or pictures.

a. Investigate any public chat rooms used by the children. b. Use filtering software to block objectionable information. e. Be alert for downloaded files with suffixes that indicate images or pictures. Parents should keep identifying information private (e.g., full name, address, telephone number) and investigate filtering software or methods of blocking out objectionable information. They should warn their children to avoid public chat rooms and forums and emphasize that everything said or anything read online may not be true. They should also be alert for downloaded files with suffixes that indicate images or pictures (e.g., .jpg, .gif, .bmp, .tif, .pcx) and consider keeping the computer in a central location in the house, rather than in a child's bedroom (USAA Educational Foundation, 2009). Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 770. Chapter 27: Safety, Security, and Emergency Preparedness - Page 770

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? a. Pull the fire alarm lever. b. Evacuate the unit. c. Confine the fire. d. Extinguish the fire.

a. Pull the fire alarm lever. 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. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 776. Chapter 27: Safety, Security, and Emergency Preparedness - Page 776

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective? a. "I will sound the alarm before I start moving a patient from a room." b. "I will rescue clients from harm before doing anything else." c. "I know that nurses are the only ones who can extinguish a fire." d. "I will leave all doors open after rescuing patients."

b. "I will rescue clients from harm before doing anything else." The RACE acronym should be used when managing a fire: Rescue, Alarm, Confine, and Extinguish. Teaching has been effective when the UAP knows to rescue patients first. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 784-786. Chapter 27: Safety, Security, and Emergency Preparedness - Page 784-786

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? a. The nurse should include a note on the client's chart that mentions the report. b. The nurse should await results of the x-ray before filing the report. c. The nurse should make a copy of the safety event report and place it in the client's medical record. d. The nurse should record the incident in the client's medical record and fill out a safety event report separately.

d. The nurse should record the incident in the client's medical record and fill out a safety event report separately.

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? A. "Check breathing and heart rate." B. "What do you think that the child might have ingested?" C. "At what time did the child ingest the substance?" D. "Induce vomiting while you wait for emergency personnel to arrive."

A. "Check breathing and heart rate." Explanation: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function. After that, rescuers attempt to identify what was ingested, how much, and when. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 760. Chapter 27: Safety, Security, and Emergency Preparedness - Page 760

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important? A. "Make sure that you have smoke detectors in your house and that they're in working order." B. "If your clothes should catch on fire, go to an open area as quickly as possible." C. "A wood-burning fireplace is a major fire risk, and it shouldn't be used unless necessary." D. "Make sure that your family's microwave oven was made after 1999; otherwise, it may be a fire risk."

A. "Make sure that you have smoke detectors in your house and that they're in working order." Explanation: A paramount fire-safety issue is smoke detectors, since approximately half of home fire deaths occur in a home without a smoke detector. This risk far exceeds that of fireplaces, even though these must be used with caution. Individuals should stop, drop and roll if clothing catches on fire. Old microwaves do not constitute a significant fire risk. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 760. Chapter 27: Safety, Security, and Emergency Preparedness - Page 760

Which topics should be included in an education plan for preventing falls in the home? Select all that apply. A. Consider the use of a raised toilet seat. B. Remove clutter from walkways. C. Consider the use of an electronic personal alarm. D. Keep electrical and telephone cords against the wall and out of walkways. E. Avoid climbing on a chair or table to reach items that are too high. F. Use a nightlight.

A. Consider the use of a raised toilet seat. B. Remove clutter from walkways D. Keep electrical and telephone cords against the wall and out of walkways. E. Avoid climbing on a chair or table to reach items that are too high. F. Use a nightlight. Explanation: Nurses should teach older clients ways to prevent falls at home. They include the following: Clean up clutter. Repair or remove tripping hazards. Install grab bars and handrails. Avoid wearing loose clothing. Lighting should be bright. Wear shoes and make them nonslip. Live on one level. The use of an electronic personal alarm is not a product that would prevent falls. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 760. Chapter 27: Safety, Security, and Emergency Preparedness - Page 760

A nurse is volunteering in a free community health clinic. One of the services offered is vehicle restraint checks for children. Which principles apply to infant and child restraints? Select all that apply. A. Infants should be rear-facing up to the age of 2 years. B. Children over 30 lb (13.5 kg) only need a lap and shoulder belt. C. A child may sit in the front seat when 8 years old D. Infants should remain in the infant seat until the age of 2 years. E. Booster seats should be used until the child is 4 ft 9 in (145 cm) tall.

A. Infants should be rear-facing up to the age of 2 years. E. Booster seats should be used until the child is 4 ft 9 in (145 cm) tall. Infants should remain in the infant seat up to the maximum weight limit or until their length exceeds the length of the seat. Children from 20 to 40 lb (9 to 18 kg) should remain in a forward-facing car seat. Due to the force of a deployed airbag, sitting in the front seat is not recommended until the child is 13 years old. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 791. Chapter 27: Safety, Security, and Emergency Preparedness - Page 791

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? A. Investigate the possibility of discontinuing his or her catheter. B. Increase the resident's physical activity to reduce evening restlessness. C. Collaborate with the resident's health care provider to have his or her diuretics discontinued. D. Limit the resident's fluid intake in order to reduce his or her urge to void.

A. Investigate the possibility of discontinuing his or her catheter. Discontinuing the catheter, if medically prudent, would eliminate the risks associated with the resident's behavior. Limiting fluid intake or reducing diuretics would be unsafe and ineffective. Similarly, increasing the resident's activity is unlikely to reduce restlessness. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 784-785. Chapter 27: Safety, Security, and Emergency Preparedness - Page 784-785

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. A. Obey the speed limit. B. Drive at night when fewer people are on the road. C. Always wear a seat belt. D. Limit the number of other adolescents in the car. E. Never text while driving.

A. Obey the speed limit. C. Always wear a seat belt. D. Limit the number of other adolescents in the car. E. Never text while driving. Explanation: Safe driving behaviors include always wearing a seat belt, limiting the number of other adolescents in the car, never texting while driving, and obeying the speed limit. Driving at night should be limited, not encouraged. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 769. Chapter 27: Safety, Security, and Emergency Preparedness - Page 769

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? A. Provide a bedside commode and ensure adequate lighting. B. Accompany the client to the bathroom every 4 hours around the clock. C. Obtain an order for insertion of an indwelling urinary catheter. D. Limit the client's fluid intake during the evening.

A. Provide a bedside commode and ensure adequate lighting. Explanation: The use of a commode can often reduce the risk of falls that is associated with ambulating to the bathroom. Falls reduction is not considered a justifiable rationale for catheter insertion. Toileting every 4 hours may or may not be adequate for the client's needs. Fluid intake should never be reduced for the sole purpose of reducing urine output. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 784-785. Chapter 27: Safety, Security, and Emergency Preparedness - Page 784-785

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? A. Reduce distressing environmental stimuli to maximize client safety B. Leave to notify the health care provider concerning a change in client status C. Apply limb restraints to ensure client safety D. Promptly document the change in client status

A. Reduce distressing environmental stimuli to maximize client safety Explanation: Added stimulation can increase the maladaptive behaviors of the client; therefore, the nurse should first reduce the distressing environmental stimuli. Proper communication of client status change is a legal requirement of nurses, and documentation provides a means of communication between interdisciplinary teams and provides continuing of care. However, notifying the health care provider and documenting the change in status are not the priority action. Restraints are to be used as a last resort in client care. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 788. Chapter 27: Safety, Security, and Emergency Preparedness - Page 788

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected the client with an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident? A. Report this sentinel event to the Joint Commission and to relevant state agencies B. File an incident report with the American Nurses Association describing plans for preventing similar events in the future. C. Offer compensation to the affected client in a timely manner, while maintaining the client's confidentiality. D. Inform the public that the incident occurred, while protecting the confidentiality of the clients.

A. Report this sentinel event to the Joint Commission and to relevant state agencies Explanation: At issue here is that the nurse directly exposed a client via direct bloodline to a client infected with HCV. The uninfected client could become infected and require lengthy treatment. Sentinel events must be reported to the Joint Commission and to relevant state agencies. Sentinel events are not normally publicized, and incident reports are not provided to the ANA. Matters related to financial compensation would likely involve the courts, not the Joint Commission or health agencies. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 774. Chapter 27: Safety, Security, and Emergency Preparedness - Page 774

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply. a. The IV is not infusing at the correct rate. b. There is spilled water on the floor. c. The skin is a bluish-color. d. The client's television is turned off. e. The client is wearing the oxygen around the neck.

A. The IV is not infusing at the correct rate. B. There is spilled water on the floor. C. The skin is a bluish-color. E. The client is wearing the oxygen around the neck. Explanation: The situational assessment includes: ABCs, IVs, tubes, oxygen, safety, and environmental safety, including the nurse's intuition, hearing, smelling, seeing, or feeling that something needs to be explored. The client wearing oxygen around the neck is a concern in a situational assessment, because the client's SpO2 may be decreased if the oxygen is not worn properly. Moreover, tubing around the neck presents a safety issue, as does spilled water on the floor. The client's television is of no importance to the situational assessment. The situational assessment should check whether the IV is infusing at a correct rate. The client's skin being a bluish color is also a concern during situational assessment; it could be related to not wearing the oxygen correctly or indicate coldness or lack of perfusion. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 784-785. Chapter 27: Safety, Security, and Emergency Preparedness - Page 784-785

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client? A. The client will not experience a fall and remains free of injury. B. The client will stay in bed. C. The client will not ambulate without assistance. D. The client will wear nonskid footwear.

A. The client will not experience a fall and remains free of injury. Explanation: Many accidental injuries and deaths are preventable. Consider the various factors and the environment that affect the client's safety and formulate expected outcomes uniquely suited to each situation and circumstance. Some expected outcomes for clients that promote safety and prevent fall injuries include: • demonstrate safety measures to prevent falls and other accidents • remain free of injury during hospitalization Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 757. Chapter 27: Safety, Security, and Emergency Preparedness - Page 757

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? A. identifying systemic factors on the unit that may have contributed to the event B. communicating the potential consequences of the near miss to the client involved C. ensuring that the client's nurse is held accountable and educated about best practice D. reinforcing the standards for nursing care to staff members who were involved

A. identifying systemic factors on the unit that may have contributed to the event Explanation: Central to creating a culture of safety is the need to identify systemic factors that may contribute to errors or near misses. Communicating with the client is necessary, but identifying systemic factors is a priority because of the implications for future clients. Focusing on the nurses who were directly involved demonstrates a narrow and short term perspective of safety, which may be perceived as punitive. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 752. Chapter 27: Safety, Security, and Emergency Preparedness - Page 752

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? A. "Do not get up without assistance for any reason." B. "Use the call bell for any needs and wear nonslip footwear." C. "You will mostly stay in bed while you are hospitalized." D. "It is important to us that you remain free from injury."

B. "Use the call bell for any needs and wear nonslip footwear." All of these teaching points are correct. However, the best action is for the nurse to teach the client how to be safe by using the call bell for assistance and wearing nonskid footwear. Telling the client that it is important for the nurse that the client remains free from injury is true, but this statement does not inform the client how to avoid becoming injured in this new environment. The client may remain in bed for a large portion of the stay, but the client will need to get up and should be taught how to safely do that. Instructing the client to not get out of bed for any reason is not healthy for the postoperative client, and it is not reasonable. Rather, the nurse teaches the client how to be safe when getting up. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 757-759. Chapter 27: Safety, Security, and Emergency Preparedness - Page 757-759

A client is brought to the emergency department after inhaling a substance suspected to be anthrax from the contents of an envelope. What symptoms experienced by the client would the nurse correlate with this substance? A. Ulcerated skin lesions B. Cough, dyspnea, and fatigue C. Abdominal pain and hematemesis D. Nausea, vomiting, and diarrhea

B. Cough, dyspnea, and fatigue The symptoms of exposure to anthrax present differently based on the means of transmission. Contact with cutaneous absorption of anthrax can be indicated by skin lesion with local edema that progresses, enlarges, ulcerates, and becomes necrotic. Gastrointestinal exposure can be indicated by nausea, vomiting, fever, abdominal pain, hematemesis, and severe diarrhea. Inhalation exposure can be indicated by fever, fatigue, cough, dyspnea, and pain; exposure of this type may progress to meningitis, septicemia, shock, and death. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 781. Chapter 27: Safety, Security, and Emergency Preparedness - Page 781

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? A. Tenth B. Fifth C. First D. Eighth

B. Fifth Explanation: Unintentional injuries are the fifth leading cause of deaths behind heart disease, cancer, stroke, and chronic obstructive lung disease. Listed are the top 3 leading causes of death in the US: Heart disease, cancer, and chronic lower respiratory diseases. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 762. Chapter 27: Safety, Security, and Emergency Preparedness - Page 762

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? A. Allow emergency personnel to apply oxygen. B. Open doors and windows. C. Recommend that carbon monoxide detectors be installed in the home. D. Wait inside until emergency personnel arrive.

B. Open doors and windows. Explanation: 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. If, while waiting for emergency personnel to arrive, the family members gain the ability to move, they can evacuate outdoors. After having the caller open doors and windows, the nurse can then provide instructions about emergency personnel and further discuss CO detectors. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 762. Chapter 27: Safety, Security, and Emergency Preparedness - Page 762

What is the best short-term outcome for a client with the nursing diagnosis of Risk for Injury related to risk-taking behaviors? A. The client will call for help when in a risky situation. B. The client will identify behaviors that would decrease the risk for injury. C. The client will seek counseling for risky behaviors. D. The client will identify risk-taking behaviors.

B. The client will identify behaviors that would decrease the risk for injury. Explanation: The best short-term outcome for a client with a Risk for Injury related to risk-taking behaviors would be to identify behaviors that would his or her risk for injury. Counseling and calling for help are long-term and unanticipated interventions that would not immediately address the identified problem. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 753-754. Chapter 27: Safety, Security, and Emergency Preparedness - Page 753-754

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? A. admitting the client to the health care facility B. administering medications to the client C. electronically reporting the results of diagnostic testing to the client's primary care provider D. transferring the client from one location in the hospital to another

B. administering medications to the client Explanation: A large proportion of adverse events in hospital settings involves medication administration. It is generally accepted that medication administration is more risky than communication of testing results, client transfers, or client admissions. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 778. Chapter 27: Safety, Security, and Emergency Preparedness - Page 778

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states: A. "My child needs a helmet if in a secured passenger bike seat." B. "My child should wear a helmet every time he rides a bike." C. "I should be able to fit two fingers between my chin and the chin strap." D. "The helmet should rest 1 in (2.5 cm) above the eyebrows."

C. "I should be able to fit two fingers between my chin and the chin strap." Explanation: The nurse should determine that additional information is needed when the participant states that the chin strap should fit two fingers underneath the chin. The chin strap needs to be snug, and the ability to fit two fingers between the strap and the chin indicates it is not snug enough. The helmet should rest 1 in (2.5 cm) above the eyebrows. Children should wear a helmet every time they ride a bike or are strapped into a bike seat as a passenger. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 768. Chapter 27: Safety, Security, and Emergency Preparedness - Page 768

Which nurse would be at the highest risk of causing a hazardous situation? A. A nurse who is transferred to another unit to assist with care B. A nurse who is administering medications to four clients C. A nurse who has worked 32 hours of overtime this week D. A nurse who has placed a client in the bed with three side rails up

C. A nurse who has worked 32 hours of overtime this week Health care staff who suffer sleep deprivation due to extended work hours and variable shift assignments are more likely to commit errors and be a factor in adverse events. The remaining three scenarios are within the normal realm of practice. A nurse transferring to another unit is able to provide care to clients within the scope of practice; this does not present a hazardous situation. Placing three side rails up assists with prevention of falls and is not classified as a restraint. Administering medications to four clients is an acceptable number of patients to be assigned to administer medications for most clinical settngs. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 754. Chapter 27: Safety, Security, and Emergency Preparedness - Page 754

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan? A. Smoking cessation B. Gun safety C. Childproofing the house D. Fire safety

C. Childproofing the house To prevent accidental injury and death in toddlers and preschoolers, parents need to childproof the home environment. Play areas should allow for exploration but still provide for safety. Smoking cessation and gun safety should be taught to adolescents. Fire safety is typically taught to school age children. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 767. Chapter 27: Safety, Security, and Emergency Preparedness - Page 767

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? A. Request a sedative from health care provider B. Assure bed alarms are activated C. Conceal IV tubing with gauze wrap D. Ask visiting family member to stay

C. Conceal IV tubing with gauze wrap Explanation: Wrapping the IV line provides protection for the site. Medications used to control behavior can be considered a chemical restraint that is an intervention of last resort. The presence of a family member may assure client safety and alleviate client anxiety, but would not necessarily protect the IV site. As well, it is inappropriate to delegate client safety observation to family members. Bed alarms alert the nurse to the client leaving his or her bed, but not interference with the IV site. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 775. Chapter 27: Safety, Security, and Emergency Preparedness - Page 775

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. A. Community population B. Type of health care facility C. Mobility D. Communication ability E. Developmental level

C. Mobility D. Communication ability E. Developmental level Explanation: 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 community's population and the type of facility that the client is in should not impact the safety of the client. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 752. Chapter 27: Safety, Security, and Emergency Preparedness - Page 752

A hospital is introducing a program that has the goal of aligning practices more closely with the Quality and Safety Education for Nurses (QSEN) project. What initiative best exemplifies QSEN competencies? A. New systems are introduced to increase communication between nurses and the members of other health disciplines. B. Hiring practices are reviewed to maximize the proportion of nurses who possess baccalaureate or graduate degrees. C. New partnerships are established between the hospital and local schools of nursing. D. Systems are reviewed with the goal of achieving the best client outcomes at the lowest cost.

C. New systems are introduced to increase communication between nurses and the members of other health disciplines. Explanation: Teamwork and collaboration is one of the core QSEN competencies, and is exemplified by increasing communication between different disciplines. The six QSEN competencies do not explicitly address financial costs of care, higher levels of education for nurses, or increased partnership between hospitals and educational institutions. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 753. Chapter 27: Safety, Security, and Emergency Preparedness - Page 753

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. A. For a restraint applied to an extremity, ensure that the restraint is tight enough that a finger cannot be inserted between the restraint and the client's wrist or ankle. B. Choose the most restrictive type of device that allows the least amount of mobility. C. Pad bony prominences. D. Check agency policy for the application of restraints and secure a physician's order. E. Remove the restraint at least every 2 hours or according to agency policy and client need. F. Fasten the restraint to the side rail.

C. Pad bony prominences. D. Check agency policy for the application of restraints and secure a physician's order. E. Remove the restraint at least every 2 hours or according to agency policy and client need. Explanation: A restraint can be applied if there is a justifiable reason, such as a client threatening the safety of another client, but a physician's order must be obtained as soon as possible. Bony prominences should be padded to protect skin integrity. The restraint should be removed so the extremity can be moved through range-of-motion and to ensure that circulation is not impaired. The least restrictive type of restraint should be chosen. A finger should be able to fit between the restraint and the body part to ensure the restraint is not too tight. The restraint should be fastened to non-moving parts of the bed. Fastening a restraint to a side rail may cause the restraint to tighten or injure the body part when the rail is lowered or raised. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 786. Chapter 27: Safety, Security, and Emergency Preparedness - Page 786

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? A. She may be developing nutritional deficiencies from poor dietary habits. B. She has lost interest in academics because she has a boyfriend now. C. She may be the victim of cyber-bullying. D. She may be beginning her menses.

C. She may be the victim of cyber-bullying. Explanation: Symptoms of cyber-bullying include faltering school achievement, absenteeism, health concerns, isolating oneself from peers/friends, and increased anxiety and depression symptoms. Adolescents may neglect academics when involved in personal relationships, but that is a common milestone of the age group. Achieving menarche may alter mood, but it is not a risk concern. Nutritional deficits can be seen in adolescence and may need to be investigated with this client, but it is not the priority at this time. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 770-782. Chapter 27: Safety, Security, and Emergency Preparedness - Page 770-782

The nurse is teaching the caregiver of an infant about safety. Which teaching will the nurse include? A. Buy protective sporting equipment. B. Place all household cleaners out of reach. C. Supervise your child on the changing table. D. Peer pressure causes children of this age to take risks.

C. Supervise your child on the changing table. Explanation: 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. Placing household cleaners out of reach, buying protective sporting equipment, and teaching about peer pressure risks are appropriate for older children, not infants. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 765. Chapter 27: Safety, Security, and Emergency Preparedness - Page 765

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 3-year-old child? A. "We place our child in a front-facing car seat in the front of the car." B. "We place our child in a rear-facing car seat in the front of the car." C. "We place our child in a rear-facing car seat in the back seat of the car." D. "We place our child in a front-facing car seat in the back seat of the car."

D. "We place our child in a front-facing car seat in the back seat of the car." Explanation: Children over the age of 2 should be placed in a front-facing car seat based on the child's weight and height. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 790. Chapter 27: Safety, Security, and Emergency Preparedness - Page 790

A new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant? A. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old and weighing less than 20 lb (9 kg). B. A rear-facing safety seat should be used for infants younger than 1 year old and weighing more than 20 lb (9 kg). C. A rear-facing safety seat should be used for infants younger than 1 year old or up to the maximum weight for the seat. D. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat.

D. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat. Explanation: Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should remain in a rear-facing safety seat. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 766. Chapter 27: Safety, Security, and Emergency Preparedness - Page 766

The nurse is discussing car safety with the mother of a 6-year-old child. The child's mother questions the need for the use of special car seats for her child. What information can be provided to her? A. "Car seats are recommended until children are at least 10 years old." B. "Your child will be safe in the car using the provided shoulder harness and lap belts." C. "Car seats are only recommended until children are 3 years old." D. "At the age of 6 your child should be using a booster seat."

D. At the age of 6 your child should be using a booster seat." Explanation: When children outgrow standard car seats, parents and caregivers should use booster seats, preferably those that use combination shoulder and lap belts, until the car seat belt fits appropriately (typically when they have reached 4 ft, 9 in [1.43 m] in height and are between 8 and 12 years of age). Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 767-791. Chapter 27: Safety, Security, and Emergency Preparedness - Page 767-791

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

The alternative measures attempted before applying the restraints Reasonable measures to avoid the use of restraints must be attempted before implementation; these measures must be documented. Verbal restraint prescriptions must be renewed every 24 hours, not every 48 hours. Neither a detailed description of the restraint application process nor the type of personal protective equipment used by the nurse during restraint application are required to be documented. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 786-789. Chapter 27: Safety, Security, and Emergency Preparedness - Page 786-789

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following? a. Activate the fire alarm and notify the appropriate person. b. Answer all telephone calls and call bells. c. Attempt to extinguish the fire. d. Alert the local fire department.

a. Activate the fire alarm and notify the appropriate person. RACE stands for Rescue - Alarm - Contain - Extinguish. The "A" in the acronym RACE stands for "activate the fire alarm and notify the appropriate person." Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 776. Chapter 27: Safety, Security, and Emergency Preparedness - Page 776

The nurse is caring for an older adult client. Which situational assessment findings establish the need for interventions? Select all that apply. a. Call light is at top of bed under the pillow. b. Bedside table with client's personal items is at the foot of the bed. c. Oxygen by nasal cannula in place; tubing on floor; flow meter at ordered 3 L. d. Bed is in low position and brakes are in place. e. Trash bag on side rail for used tissues.

a. Call light is at top of bed under the pillow. b. Bedside table with client's personal items is at the foot of the bed. c. Oxygen by nasal cannula in place; tubing on floor; flow meter at ordered 3 L. The nurse performs the situational assessment by observing the client, family, and environment to identify and solve any potential problems before they can lead to safety concerns. The nurse should assess the need to place the bedside table by the client to provide items at close reach and decrease risks for falls. The nurse should establish that the oxygen tubing needs to be connected to the flow meter. The nurse determines that the bed is in its safest position. The trash bag secured on the side rail provides a convenient location for used tissues, decreasing clutter. The nurse determines that the call light needs to be secured and within reach for the client to use it. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 784-785. Chapter 27: Safety, Security, and Emergency Preparedness - Page 784-78

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order? a. Ensure that two fingers can be inserted between the restraint and the client's extremity. b. Use a quick-release knot to tie the restraint to the side rail. c. Remove the restraint at least every 4 hours, or according to facility policy. d. Apply restraints to the hands or wrists, never to the ankles.

a. Ensure that two fingers can be inserted between the restraint and the client's extremity. Restraints should be sufficiently loose for two fingers to be inserted between the restraint and the extremity. Restraints can be placed on ankles; quick-release knots should be tied to the bed frame, not the side rail. Restraints should be removed every 2 hours. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 786-789. Chapter 27: Safety, Security, and Emergency Preparedness - Page 786-789

What is the primary role of the nurse in the care of clients who experience domestic violence? a. Providing prompt recognition of the potential or actual threat to safety b. Calling the police c. Identifying health education and counseling measures for the family d. Serving as a witness in court

a. Providing prompt recognition of the potential or actual threat to the safety 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 771. Chapter 27: Safety, Security, and Emergency Preparedness - Page 771

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care? a. Risk for Injury Related to Agitation b. Chronic Confusion Related to Long-Standing Alcohol Use c. Impaired Bed Mobility Related to Muscle Wasting d. Noncompliance Related to Medication Regimen

a. Risk for Injury Related to Agitation The client's risk of self-injury or injury to others is the justification for restraint use. Restraints are not normally used to address noncompliance or chronic confusion unless there is a consequent safety risk. Impaired bed mobility is not a justification for restraints. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 786-789. Chapter 27: Safety, Security, and Emergency Preparedness - Page 786-789

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client 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 client? a. Take the restraints off, stay with her, and talk gently to her. b. Talk with the client's family about taking her home because she is out of control. c. Leave the restraints on and talk with her, explaining that she must calm down. d. Sedate her with sleeping pills and leave the restraints on.

a. Take the restraints off, stay with her, and talk gently to her. 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 client and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the client to talk to her is going to cause further agitation and bruising of her wrists. The client's condition—not confusion and agitation—dictates when the client is discharged. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 774-775. Chapter 27: Safety, Security, and Emergency Preparedness - Page 774-775

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? a. The nurse should question the client about the source of the bruises. b. The nurse should request permission from the client to photograph the bruises. c. The nurse should notify the primary care physician about the bruises. d. The nurse should contact the facility's social services department.

a. The nurse should question the client about the source of the bruises. The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 767. Chapter 27: Safety, Security, and Emergency Preparedness - Page 767

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client? a. an 84-year-old male with four recent driving violation b. a 42-year-old female who is a single mom with a sick child home from school c. a 12-year-old male who sprained his wrist skateboarding d. a 16-year-old pregnant female who has morning sickness

a. an 84-year-old male with four recent driving violation 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. The 12-year-old should not experience sensory issues with a sprain of the wrist. The 42-year-old may be stressed but is not experiencing illness. The 16-year-old is experiencing illness, but it is not a sensory-perceptual alteration. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 755-756. Chapter 27: Safety, Security, and Emergency Preparedness - Page 755-756

When educating families on fire safety, it is important to: a. have a meeting place outside the home. b. account for all members and then exit. c. use extension cords to prevent shock. d. keep a fire extinguisher in a closet.

a. have a meeting place outside the home. The whole family should regularly practice crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in an area with access and not a closet. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 776. Chapter 27: Safety, Security, and Emergency Preparedness - Page 776

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: a. mass trauma terrorism. b. chemical terrorism. c. nuclear terrorism. d. bioterrorism.

a. mass trauma terrorism. 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 780. Chapter 27: Safety, Security, and Emergency Preparedness - Page 780

Which level of health care provider may make the decision to apply physical restraints to a client? a. nurse practitioner b. senior personal care assistant c. RN nurse manager d. LPN team leader

a. nurse practitioner Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such as The Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician assistant. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 776. Chapter 27: Safety, Security, and Emergency Preparedness - Page 776

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply. a. Revamping the licensing requirements for foreign-educated nurses b. Client-centered care c. Teamwork and collaboration d. Establishment of clinical career ladders e. Quality improvement (QI)

b. Client-centered care c. Teamwork and collaboration e. Quality improvement (QI) The Quality and Safety Education for Nurses (QSEN) project has been designed to provide a framework for the knowledge, skills, and attitudes necessary for future nurses. The six competencies include client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Requirements for foreign-educated nurses and the establishment of clinical career ladders are not explicit focuses of the QSEN competencies. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 753-779. Chapter 27: Safety, Security, and Emergency Preparedness - Page 753-779

The unlicensed assistive personnel (UAP) 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? a. Administer the client's sedative as ordered. b. Initiate use of a bed alarm. c. Contact the physician for a restraint order. d. Put up all four side rails on the bed.

b. Initiate use of a bed alarm. To prevent a fall, the nurse should attempt to prevent the confused client from getting out of bed by himself by using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all four side rails 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 himself or others. Contacting the physician for a restraint order or sedative is appropriate if the least restrictive measures do not work. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 775. Chapter 27: Safety, Security, and Emergency Preparedness - Page 775

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? a. CMS may choose to divert clients to other health care facilities in the future. b. The hospital must bear any costs incurred for treating the client's injury. c. The hospital will be fined by CMS because the client developed a pressure injury. d. CMS will bear the hospital's costs if the client chooses to sue the hospital.

b. The hospital must bear any costs incurred for treating the client's injury. If "never events" occur while a client is hospitalized, the cost of the care associated with that event will not be paid by CMS, but will be borne by the hospital. Fines are not levied against the hospital, however, and CMS does not actively divert clients to other facilities. CMS does not pay damages on behalf of hospitals. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 772. Chapter 27: Safety, Security, and Emergency Preparedness - Page 772

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should: a. hold a facility-wide meeting to identify strategies for making improvements to the safety of residents. b. fill out an incident report, with the goal of preventing a similar event in the future. c. complete an incident report to determine who was primarily responsible for the event. d. document strategies in the client's health record for preventing future incidents.

b. fill out an incident report, with the goal of preventing a similar event in the future. Incident reports are primarily used to facilitate improvements, not to determine culpability. A client's health record requires skill to document the necessarry behavior and results and allows for adapting nursing care planning; a client health record must not discuss aspects particular to the incident report or facility issues. Holding a meeting will likely be necessary or helpful, but does not replace the need to document the event in the form of an incident report. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 778. Chapter 27: Safety, Security, and Emergency Preparedness - Page 778

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse? a. the 6-year-old riding a bike on the playground with his friend b. the 2-year-old leaning against the screen of a window in a classroom c. the 2-year-old and 6-year-old each holding the mother's hand d. the 2-year-old helping mom to open the front door of the school

b. the 2-year-old leaning against the screen of a window in a classroom Windows pose a serious risk to toddlers. Screens can easily give way to the weight of a toddler. This is unsafe behavior. Toddlers thrive in exploration. The parent must be fastidious in monitoring and helping the toddler accomplish tasks. The buddy system is a great safety tool for school-age children. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 767. Chapter 27: Safety, Security, and Emergency Preparedness - Page 767

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety? a. "any helmet is appropriate for bicycle riding because all children should wear helmet when riding." b. "the chin strap on the helmet should be adjusted to fit loosely so that it does not choke the child." c. "parents are effective role models for children when they also wear helmets while riding." d. young children secured in a bicycle passenger seat do not have to wear a helmet."

c. "parents are effective role models for children when they also wear helmets while riding." Parents are effective role models for children when they also wear helmets while riding. Helmets that have been damaged in a crash should not be worn. The chin strap should fit snuggly, not loosely. Young children who are secured in a bicycle passenger seat must also wear a helmet. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 768. Chapter 27: Safety, Security, and Emergency Preparedness - Page 768

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use? a. 40-year-old female who is working two jobs b. 34-year-old male who does not use a seat belt c. 19-year-old male college student majoring in physics d. 25-year-old female who just accepted her first job

c. 19-year-old male college student majoring in physics Young adults, particularly those who just became emancipated from parental supervision, are at the highest risk for alcohol and drug use. Other clients may have other safety risk factors, but are not at a proportionately higher risk for alcohol and drug use. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 769. Chapter 27: Safety, Security, and Emergency Preparedness - Page 769

A school-age 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 client? a. Initiation of a peripheral intravenous (IV) line for fluid administration b. Assessment of head circumference c. Assessment of vital signs and respiratory status d. Evaluation of all of his cranial nerves

c. Assessment of vital signs and respiratory status 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. Head circumference is only beneficial in children less than 2 years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment. Assessment comes before intervention in the nursing process and more assessment is needed for this client before the need for an IV line is determined. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 775. Chapter 27: Safety, Security, and Emergency Preparedness - Page 775

What best describes the nurse's role in disaster preparedness? a. Administration of all of the medications b. Performance of all of the skills such as IV insertion and wound care c. Multiple roles, including triage and the distribution of resources d. Counseling the victims and families

c. Multiple roles, including triage and the distribution of resources Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 783. Chapter 27: Safety, Security, and Emergency Preparedness - Page 783

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. a. Withhold information from family regarding restraints due to HIPAA. b. Maintain restraints until discharge. c. Obtain order from a licensed provider within minutes of restraint application. d. Offer regular, frequent opportunities for toileting. e. Check circulation and skin condition every 2 hours.

c. Obtain an order from a licensed provider within minutes of restraint application. d. Offer regular, frequent opportunities for toileting. e. Check circulation and skin condition every 2 hours. An order for restraints from the licensed health care provider must be obtained within minutes after the restraint is applied. Frequent and regular nursing assessments are required of the restrained client's vital signs; circulation; skin condition or signs of injury; psychological status and comfort; and readiness for discontinuing the restraint. The nurse must explain the need for restraints with the family. When the assessment findings indicate that the client has improved, restraints must be removed. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 788. Chapter 27: Safety, Security, and Emergency Preparedness - Page 788

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? a. Evacuate clients and staff. b. Attempt to extinguish the fire. c. Rescue anyone who is in immediate danger. d. Activate the fire alarm on the unit.

c. Rescue anyone who is in immediate danger. The acronym "RACE" can be used as a guide to the immediate response to fire. This involves rescuing anyone in immediate danger (R); pulling the alarm, calling "code red," and alerting appropriate personnel (A); confining the fire by closing doors and windows (C); evacuating clients and other people to a safe area (E). Extinguishing the fire is not part of the immediate response. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 776. Chapter 27: Safety, Security, and Emergency Preparedness - Page 776

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan? a. Keep all pots and pans in lower cabinets. b. Lock all cabinets that contain cleaning supplies. c. Restrain the baby in a car seat. d. Give warm bottles of formula to the baby.

c. Restrain the baby in a car seat. The client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets, giving warm bottles of formula to the baby, and keeping all pots and pans in lower cabinets are secondary teachings. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 765. Chapter 27: Safety, Security, and Emergency Preparedness - Page 765

The nurse is creating a plan of care for the older adult who 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? a. Risk for Injury related to substance use b. Altered Sensory Perception related to decreased visual acuity c. Risk for Poisoning related to poor eyesight and the inability to read medication labels d. Risk for Falls related to immobility

c. Risk for Poisoning related to poor eyesight and the inability to read medication labels Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in reading the labels of the multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance use in this client. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 772. Chapter 27: Safety, Security, and Emergency Preparedness - Page 772

What generalization can be made about safety in client care? a. Although safety is a basic human need, it is provided by self-care. b. Safety is an important need, but not as important as self-actualization. c. Safety is a paramount concern underlying all nursing care. d. Health care providers exclude safety as client need.

c. Safety is a paramount concern underlying all nursing care. Safety and security are basic human needs. Safety, or freedom from danger, harm, or risk, is a paramount concern that underlies all nursing care, and client safety is a responsibility of all health care providers. Safety is not related to the client's self-care but the client's environment, whether in the acute care setting or at home. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 752. Chapter 27: Safety, Security, and Emergency Preparedness - Page 752

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? a. "Never keep firearms in the home with young children." b. "Store medications in a locked area to prevent children from getting into them." c. "Never smoke in the bed in the house when young children are present." d. "Always provide close supervision for young children when they are in or around pools and bathtubs."

d. "Always provide close supervision for young children when they are in or around pools and bathtubs." 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 762. Chapter 27: Safety, Security, and Emergency Preparedness - Page 762

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address? a. No extension cords are being used. b. Outlets and switches have cover plates. c. Machines used infrequently are unplugged. d. A hair dryer is placed next to the sink.

d. A hair dryer is placed next to the sink. Electrical shock can result if appliances such as a hair dryer come in contact with water. The hair dryer should be removed away from the sink. Other findings reflect appropriate safety measures. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 766. Chapter 27: Safety, Security, and Emergency Preparedness - Page 766

A client arrives at the emergency department after an industrial explosion involving an unknown chemical contaminant. What is the nurse's priority action? a. Flush skin while rinsing with sterile saline b. Identify chemical agent before treating c. Assess client's respiratory depth and effort d. Activate external disaster protocol

d. Activate external disaster protocol Before performing assessments or interventions, it is essential that the nurse inform others about the incident in order to mobilize assistance. In most cases, this involves the activation of an emergency protocol. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 779-780. Chapter 27: Safety, Security, and Emergency Preparedness - Page 779-780

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment? a. Suggest a high-fiber, low-fat diet b. Restrict consumption of liquids before bedtime c. Provide a pamphlet on maintaining healthy sleep habits d. Encourage exercise that improves balance and muscle strength

d. Encourage exercise that improves balance and muscle strength Falls are a significant health hazard for the older adult. Regular exercise has a positive effect on bone and muscle strength, balance, and flexibility of joints. A high-fiber, low-fat diet may be advisable for many older adults, but it is not specific to promoting client safety in the home. Information about promoting regular sleep may improve safety for select groups of clients, but will not have the specific benefits for fall prevention achieved by improved balance and muscle strength. Avoiding liquids before bedtime may decrease the need for night time trips to the bathroom, and may be a valid recommendation for some parties. However, the outcome benefits are not as specific to fall prevention in health older adults as exercise, balance, and muscle strength. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 772. Chapter 27: Safety, Security, and Emergency Preparedness - Page 772

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? a. Use an extension cord to provide freedom of movement. b. Tape the electrical cord of the pump to the floor. c. Run the electrical cord of the pump under the carpet. d. Obtain a three-prong grounded plug adapter.

d. Obtain a three-prong grounded plug adapter. The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard. Taping the electrical cord to the ground and running the electrical cord under the carpet are not appropriate actions for electrical safety. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, Preventing Equipment-Related Accidents, p. 777. Chapter 27: Safety, Security, and Emergency Preparedness - Page 777

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include? a. Place all household cleaners out of reach. b. Buy protective sporting equipment. c. Supervise your child on the changing table. d. Peer pressure causes children of this age to take risks.

d. Peer pressure causes children of this age to take 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. Buying protective sporting equipment, placing household cleaners out of reach, and supervising the child on the changing table are not age-appropriate teachings to include. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 766. Chapter 27: Safety, Security, and Emergency Preparedness - Page 766

A nurse is caring for an 18-month-old client after a tracheostomy. The is recovering well and noted a desire to be more active. The nurse selects a toy from the playroom for the client to play with. Which toy is most developmentally appropriate? a. marbles b. dominos c. a beaded bracelet d. a rocking horse

d. a rocking horse All of these toys present a choking hazard except for the rocking horse. Rocking horses are a great toy for development of leg muscles. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 788-789. Chapter 27: Safety, Security, and Emergency Preparedness - Page 788-789

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to: a. falls from beds. b. play-related injuries. c. falls from staircases. d. automobile accidents.

d. automobile accidents. 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. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 768-769. Chapter 27: Safety, Security, and Emergency Preparedness - Page 768-769

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? a. has client sit in bed for a few moments before standing b. places bed at lowest setting c. clears a path from bed to bathroom d. provides slippers for ambulation

d. 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. Placing the bed at the lowest setting, clearing a path from the bed to the bathroom, and having the client sit in bed before standing increase safety while minimizing risk for falls. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, pp. 784-786. Chapter 27: Safety, Security, and Emergency Preparedness - Page 784-786

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? a. Normal rebellion b. Poor judgment c. Past experience d. social pressure

d. social pressure As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 754. Chapter 27: Safety, Security, and Emergency Preparedness - Page 754

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? a. the nurse should contact the facility's social service department b. the nurse should request permission from the client to photograph the bruises c. the nurse should notify the primary care physician about the bruises d. the nurse should question the client about the source of the bruises

d. the nurse should question the client about the source of the bruises The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 27: Safety, Security, and Emergency Preparedness, p. 767. Chapter 27: Safety, Security, and Emergency Preparedness - Page 767