Ch 23 practice quiz
A nurse is caring for an 18 month-old boy status post a tracheostomy. He is recovering well and wanting to be more active. The nurse selects a toy from the playroom for him to play with. Which toy is most developmentally appropriate?
A rocking horse
An 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?
Activate the fire alarm and notify the appropriate person.
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 is reviewing a healthcare provider's orders in the electronic health record (EHR) and notices several abbreviations. What is the appropriate nursing action?
Contact healthcare provider to clarify order.
The facility where the nurse works has changed from latex gloves to vinyl, powder-free gloves to protect clients with latex allergies. Which teaching, if any, will the nurse provide to the unlicensed assistive personnel (UAP) about this new type of glove?
Gloves must be changed every 30 minutes to maintain barrier protection.
What teaching will the community health nurse include for parents of toddlers?
Household cleaners must be kept out of reach.
The nurse is caring for a client who scored 3 on the Hendrich II Fall Risk Model. Which intervention is appropriate? (Select all that apply.)
Implement normal fall prevention measures. Document the finding in the electronic health record (EHR).
A nurse is preparing to provide care to a client who is receiving radiation therapy for cancer; the radiation source will be kept in the client's room. Which action would be most important for the nurse to do?
Limit own exposure to radiation to the minimum time.
Nurses provide many interventions to prevent falls in health care settings. What would be an appropriate intervention to prevent falls?
Lock wheels on beds and wheelchairs.
A nurse is assigned to care for a hospitalized toddler. Which activity should be the highest priority for the nurse?
Protect the toddler from injury.
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 preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?
Restrain the baby in a car seat.
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?
The 2-year-old leaning against the screen of a window in a classroom.
The nurse needs to plan the interventions necessary to reduce fall risks for the older adult clients at her facility. Which is the strongest indicator that a client is at risk for falls?
The client has fallen before.
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 staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?
a dose of an antipsychotic
The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include:
polypharmacy and use of multiple extension cords.
Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy?
raising all side rails while the client is in bed
The nurse is caring for a client who has been repetitively pulled at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered?
temporary application of devices that reduce the client's ability to move arms
There is a fire in the neurology unit of a health care facility. What would be most appropriate to avoid in this situation?
use of elevators