NURS 121 PrepU CHapter 27

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?

"Check breathing and heart rate."

A nurse failed to document the administration of a client's warfarin and the nurse on the next shift administered the drug again, believing that it had been overlooked. When performing root cause analysis, what question should be asked first?

"What could the two nurses have done to ensure this did not happen?"xxf

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week

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

Arrange for a skilled home care assessment

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation

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

Avoid unattended baths for the toddler.

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What identified nursing concern provides the clearest justification for the use of physical restraints during this client's care?

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

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

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

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.

Drowsiness Headache Vomiting

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

Place all household cleaners out of reach.

The registered nurse is caring for a client with a waist restraint. Which tasks should the nurse delegate safely to the unlicensed assistive personnel (UAP)? Select all that apply.

Provide a bedpan and pericare. Obtain, record, and report vital signs.

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

Refrain from using extension cords.

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

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

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:

automobile accidents.

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What identified nursing concern provides the clearest justification for the use of physical restraints during this client's care?

injury risk related to agitation

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

social pressure

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 hair dryer is placed next to the sink.

What teaching will the community health nurse include for parents of toddlers?

Household cleaners must be kept out of reach

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

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

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

"I will rescue clients from harm before doing anything else."

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?"

A school-age child is admitted to the emergency room with a possible 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?

Assessment of vital signs and respiratory status

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

Clear clutter in the walkways of the new home.

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

Client-centered care Teamwork and collaboration Quality improvement (QI)

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

Conceal IV tubing with gauze wrap

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?

Cough, dyspnea, and fatigue

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

Implement drowning prevention strategies.

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?

Initiate use of a bed alarm.

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

Involve family members in the client's care.

A nurse makes a medication error and reports it to the nurse manager, requesting assistance filling out the incident report. What should the nurse manager educate the nurse about regarding the incident report? Select all that apply.

It should provide a clear, concise recording of the situation It should include factual information about the incident. Completion of the incident report should be noted in the nurse's notes.

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

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

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?

Obtain a three-prong grounded plug adapter.

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

Open doors and windows.

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

Providing prompt recognition of the potential or actual threat to safety

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?

Pull the fire alarm lever.

A nurse is completing an intake assessment. The nurse notes that an older adult client appears to have bruises in varying stages of healing. Which is the nurse's most appropriate initial acti

Question the client about the source of the bruises.

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first?

Reduce distressing environmental stimuli to maximize client safety

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply.

Remove extension cords from open spaces. Check the batteries in all smoke detectors. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas.

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

She may be the victim of cyber-bullying.

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

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?

The nurse should question the client about the source of the bruises.

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

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

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?

The report provides a detailed and objective account of the circumstances before, during, and after the event.

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?

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.

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

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

The school nurse is providing education on poisoning risks to adolescent students. Which topic does the nurse include in the teaching?

experimentation with drugs and inhalants

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:

fill out an incident report, with the goal of preventing a similar event in the future.

The residential home nurse is caring for a client who lives in an assisted living unit. In designing a plan of care to prevent fires, the nurse identifies which as the highest risk to the client?

gas stove

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

identifies client's full name and date of birth

The staff at a day-surgery clinic are meeting because there have been two significant medication errors committed over the past few weeks. To prevent future medication errors, what is the priority action for the nurse's to take?

take measures to ensure that nurses are not disturbed when obtaining and administering medications