Ch. 27 PrepU Questions

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. The adult child asks, "What can I do to keep my parent safe?" What are the best instruction(s) by the nurse? Select all that apply. A. Provide frequent reorientation. B. Ensure the parent engages in regular exercise. C. Increase the parent's social interaction. D. Ensure the parent takes naps frequently. E. Ensure that the parent's routine changes frequently.

A, B, C

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply. A. A person with a history of falls is likely to fall again. B. Some people are more at risk for accidents than others. C. Fires are responsible for most hospital incidents. D. Between 15% and 25% of falls result in fractures or soft tissue injury. E. A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

A, B, E

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. Inform the public that the incident occurred, while protecting the confidentiality of the clients. C. File an incident report with the American Nurses Association describing plans for preventing similar events in the future. D. Offer compensation to the affected client in a timely manner, while maintaining the client's confidentiality.

A.

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 or up to the maximum weight for the seat. B. 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). 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 younger than 1 year old and weighing more than 20 lb (9 kg).

A.

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. Obtain an order for insertion of an indwelling urinary catheter. C. Limit the client's fluid intake during the evening. D. Accompany the client to the bathroom every 4 hours around the clock.

A.

What is the most appropriate outcome for the client who has a nursing diagnosis of "Risk for Injury related to the use of assistive mobility devices in an unfamiliar environment?" A. The client will demonstrate safety measures to prevent falls. B. The client will establish safety priorities with family members. C. The client will identify resources for safety information. D. The client will identify unsafe situations in his or her environment.

A.

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

A.

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 identify risk-taking behaviors. D. The client will seek counseling for risky behaviors.

B.

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. A. Assess the client's need to continue the waist restraint. B. Chart the skin findings during the 2-hour check. C. Provide a bedpan and pericare. D. Determine if the waist restraint is too tight. E. Obtain, record, and report vital signs.

C, E

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. Respond to the past history of the client (including previous falls) to determine the need for restraints. B. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. C. Individualize the use of restraints and choose the most easily used device. D. 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.

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

D.

The nurse is caring for a school-age child and notices a variety of circular burns on the back and legs in various stages of healing. What action should the nurse take related to this suspicion? A. Inform the parent that abuse is suspected. B. Because the nurse is not sure, observation of the parents behavior will be done. C. Call the police. D. Notify the National Abuse Hotline.

D.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and is actively trying to harm another client in the unit. What action should the nurse take? A. Step in front of the client so that the other client will be protected. B. Call for assistance to remove the client from the area. C. Forcefully remove the client and place in four-point restraints. D. Inject the client while being restrained with antipsychotic medication.

B.

The nurse uses the QSEN competency of Informatics when planning care for clients. What is an example of the use of this skill? A. The nurse works collaboratively with a dietitian to devise a client meal plan. B. The nurse orients a visually impaired client to the hospital room. C. The nurse checks with the client for priorities when planning client care. D. The nurse researches new technological advances in the treatment of cancer.

D.