ch 27 safety fundamentals

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

Always wear a seat belt. Limit the number of other adolescents in the car. Never text while driving. Obey the speed limit.

11. What safety device for children is mandated by law in all 50 states? A) Bumper pads in baby cribs B) Infant car seats and carriers C) Automatic hot water heater controls D) Parental controls for Internet access

Ans: B Feedback: All 50 states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle.

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention? Teach client to wear Medic-Alert bracelet. Apply an allergy-alert identification bracelet on the client. Notify the interdisciplinary healthcare team to use nonlatex equipment. Flag the room door.

Apply an allergy-alert identification bracelet on the client.

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

Avoid climbing on a chair or table to reach items that are too high. Use a nightlight. Remove clutter from walkways. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat.

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? Allow the child to swim with friends. Instruct the toddler not to go near the pool. Avoid unattended baths for the toddler. Monitor the activities of the toddler.

Avoid unattended baths for the toddler.

A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 100/56, apical pulse 56, respiratory rate 12. Which of the vital signs should be addressed immediately? A. Respiratory rate B. Temperature C. Apical pulse D. Blood pressure

B

The nurse has placed a patient on high-risk alert for falls. Which of the following observations by the nurse would indicate that the patient has an understanding of this alert? A. The patient removes the high alert armband to bathe. B. The patient wears the red nonslip footwear. C. The call light is kept on the bedside table. D. The patient insists on taking a "water" pill on home schedule in the evening.

B

The nurse identifies that a patient has received Mylanta (simethicone) instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the problem of indigestion. The nurse's next intervention is to A. Do nothing, no harm has occurred. B. Assess and monitor the patient. C. Notify the physician, treat and document. D. Complete an incident report.

B

A nurse is in the hallway assisting a patient to ambulate and hears an alarm sound. What is the best next step for the nurse to take? A. Seek out the source of the alarm. B. Wait to see if the alarm discontinues. C. Ask another nurse to check on the alarm. D. Continue ambulating the patient

C

During the admission assessment, the nurse assesses the patient for fall risk. Which of the following has the greatest potential to increase the patient's risk for falls? A. The patient is 59 years of age. B. The patient walks 2 miles a day. C. The patient takes Benadryl (diphenhydramine) for allergies. D. The patient recently became widowed

C

The nurse is caring for a client with a latex allergy. When the dietary tray arrives, the nurse notes that it contains a hamburger with lettuce and tomato, baked potato, apple, chocolate chip cookie, and small serving of milk. What is the appropriate nursing action? Add butter and salt to the baked potato. Remove the chocolate chip cookie from the tray. Exchange the serving of milk for juice. Call Nutrition Services for a plain hamburger.

Call Nutrition Services for a plain hamburger.

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

Centers for Disease Control and Prevention

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

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.

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. Mobility Communication ability Developmental level Type of health care facility Community population

Communication ability Developmental level Mobility

A home health nurse is performing a home assessment for safety. Which of the following comments by the patient would indicate a need for further education? A. "I will schedule an appointment with a chimney inspector next week." B. "Daylight savings is the time to change batteries on the carbon monoxide detector." C. "If I feel dizzy when using the heater, I need to have it inspected." D. "When it is cold outside in the winter, I can warm my car up in the garage."

D

The nurse is precepting a student nurse and is careful to check with the student all components of the medication process. The nurse explains to the student that most errors occur in A. Ordering and transcribing. B. Dispensing and administering. C. Dispensing and transcribing. D. Ordering and administering

D

The nurse is providing information regarding safety and accidental poisoning to a grandmother who will be taking custody of a 1-year-old grandchild. Which of the following comments would indicate that the grandmother needs further instruction? A. "The number for poison control is 800-222-1222." B. "Never induce vomiting if my grandchild drinks bleach." C. "I should call 911 if my grandchild loses consciousness." D. "If my grandchild eats a plant, I should provide syrup of ipecac."

D

The school nurse is evaluating a school's response to a fire drill. Which action requires the school nurse to provide teaching to the schoolteachers, staff, and students? (Select all that apply.) Children in wheelchairs have teachers assist them during evacuation. Windows to the building are closed. Hallways are cleared of visitors. Doors of classrooms and offices are open. Elevators are used to increase speed of vacating the building.

Doors of classrooms and offices are open. Elevators are used to increase speed of vacating the building.

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? Fifth Tenth First Eighth

Fifth

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? Machines used infrequently are unplugged. No extension cards are being used. Hair dryer is placed next to the sink. Outlets and switches have cover plates.

Hair dryer is placed next to the sink.

The older adult will have an increased risk for developing which of the following? Fire hazards Poisoning Gunshot wounds Heatstroke

Heatstroke

Which statement should the nurse include in the education plan regarding safety issues for a group of adult clients? Environmental lead exposure is a primary cause of death in adult clients. In most age groups, motor vehicle accidents are major causes of death. Suicide is the leading cause of death in adults and adolescents. Occupational safety practices can eliminate all workplace hazards.

In most age groups, motor vehicle accidents are major causes of death.

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? Hiring practices are reviewed in order to maximize the proportion of nurses who possess baccalaureate or graduate degrees. Systems are reviewed with the goal of achieving the best client outcomes at the lowest cost. New systems are introduced to increase communication between nurses and the members of other health disciplines. New partnerships are established between the hospital and local schools of nursing.

New systems are introduced to increase communication between nurses and the members of other health disciplines.

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

Rescue anyone who is in immediate danger.

The home health nurse will visit a client for the first time in the home. What safety measures will the nurse employ when visiting the client? Select all that apply. Ask the client to secure animals in another room or outside before the visit. Ensure the nurse's automobile is in good condition and can be driven to the client's home. Carry a cell phone at all times. Place plenty of cash in the nurse's pocket for emergency use. Schedule an appointment with the client prior to the visit.

Schedule an appointment with the client prior to the visit. Ask the client to secure animals in another room or outside before the visit. Ensure the nurse's automobile is in good condition and can be driven to the client's home. Carry a cell phone at all times.

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

She may be the victim of cyber-bullying.

A nurse is assessing a client who was exposed to botulism from contaminated food supplies. Which symptom would the nurse expect to find in this client? Flu-like symptoms Skeletal muscle paralysis that progresses symmetrically and in a descending manner Petechial hemorrhages Skin lesion with local edema that progresses, enlarges, ulcerates, and becomes necrotic

Skeletal muscle paralysis that progresses symmetrically and in a descending manner

The nurse begins a shift and finds that the wrong medication has been administered to a client. After completing a safety event report, what should the nurse do next? Submit the safety report to the appropriate department within the facility so that it can be reviewed. File the safety event report in the appropriate file and document in the nurse's notes the date and time that it was filed. Place the safety event report in the client's medical record for future reference. Make a copy of the safety event report for the client.

Submit the safety report to the appropriate department within the facility so that it can be reviewed.

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

Supervise your child on the changing table.

A mass casualty event has occurred in a community. Many health care workers have been employed to assist. A nursing student has volunteered services. With which tasks would the nursing student be asked to assist? Select all that apply. Hold pressure on a wound that will not stop bleeding. Obtain extra supplies, such as intravenous bags and tubing, dressings, and gloves. Triage clients by severity of injuries. Administer intravenous pain medication to a client reporting severe pain. Take clients' vital signs.

Take clients' vital signs. Obtain extra supplies, such as intravenous bags and tubing, dressings, and gloves. Hold pressure on a wound that will not stop bleeding.

List three factors that are contributors to falls for the elderly.

The following are all contributing factors to falls: age greater than 65, history of falls, impaired vision and/or hearing, altered gait/impaired mobility, medication regimen and polypharmacy, postural hypotension, slowed reaction time, confusion/disorientation, unfamiliar environment.

Which patient will the nurse see first?

a 56 year old patient with oxygen using an electric razor for grooming

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 geriatric chair with a tray side rails a dose of an analgesic a dose of an antipsychotic

a dose of an antipsychotic

The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take?

a, b, c, d a- close all doors b- note evacuation routes c- note oxygen shut-offs d- move bedridden patients in their bed

A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?

applying the restraint

The nurse has delegated several parts of basic care for a client who is a fall risk to an unlicensed assistive personnel (UAP) member. Which UAP action requires nursing intervention? assuring that there is a clear path between the bathroom and bed assisting the client to put on slippers prior to ambulation placing the bed into the lowest setting reminding the client to sit on the bed for a few moments before standing

assisting the client to put on slippers prior to ambulation Slippers do not offer much support or traction. The nurse should intervene to remind the UAP that better footwear should be utilized. Other actions are appropriate and do not require further nursing intervention, other than regular supervision during delegated activities.

The nurse is caring for a client that was brought to the emergency department after a building fire. Which assessment finding alerts the nurse to possible smoke inhalation? (Select all that apply.) mild cough jaundice impaired judgement lowered body temperature black debris in nasal passages

black debris in nasal passages impaired judgement mild cough

The nurse is performing the "Timed Get Up and Go (TUG)" assessment. Which actions will the nurse take?

c, d, f c- instructs the patient to walk 10 feet as quickly and safely as possible d- observes for unsteadiness in patient's gait f- allows the patient a practice trial

A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session?

disconnect items before cleaning

Health care workers may be exposed to a common occupational injury such as: carbon monoxide exposure. inadvertent needlestick. sensory deprivation. Intimate Partner Violence (IPV).

inadvertent needlestick.

The nurse is presenting an education session on safety for parents of adolescents. Which information will the nurse include in the teaching session?

increased aggressiveness and blood spots on the clothing may indicate substance abuse

A patient is admitted and is placed on full precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?

keep the patient on fall risk until discharge

The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?

manage all patients using standard precautions

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: bioterrorism. chemical terrorism. mass trauma terrorism. nuclear terrorism.

mass trauma terrorism.

The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next?

notify the health care provider

A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?

orthostatic hypotension

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? "Your child will be safe in the car using the provided shoulder harness and lap belts." "Car seats are recommended until children are at least 10 years old." "At the age of 6 your child should be using a booster seat." "Car seats are only recommended until children are 3 years old."

"At the age of 6 your child should be using a booster seat."

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

"Check breathing and heart rate."

A large health care organization has committed to promoting a just culture when adverse events and near misses take place. Which question will guide the organization's response when a nurse commits an error? "What is the organization's legal liability in this matter?" "How did the nurse's actions contribute to this error?" "Have the client and the family been informed about this?" "How have other organizations responded to nurses in events like this?"

"How did the nurse's actions contribute to this error?" Key to the establishment of a just culture is a recognition that not all errors are the same, and that nurses' contributions to errors vary greatly. Legal liability, the response of other organizations, and communication with the client are valid considerations, but none directly promote the establishment of a just culture.

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 under the chin strap." "The helmet should rest 1 inch above the eyebrows." "My child needs a helmet if he is in a secured passenger bike seat." "My child should wear a helmet every time he rides a bike."

"I should be able to fit two fingers under the chin strap."

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: peeling paint and easy access to the backyard pool. household cleaners stored under the sink and hanging cords on window blinds. risky behaviors and cyber-bullying. polypharmacy and use of multiple extension cords.

polypharmacy and use of multiple extension cords.

The occupational health nurse is planning a safety in-service for a group of clerical workers. Which topic would be most beneficial? the use of protective clothing the use of ear plugs appropriate storage of combustable cleaning solutions principles of body alignment

principles of body alignment The clerical worker is primarily sedentary. The greatest concern would relate to body alignment and positioning. Ear plugs would be most appropriate for the factory worker. The use of protective clothing and the storage of hazardous materials would be topics best suited for janitorial workers.

A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in this teaching session?

proper fit of a bicycle helmet

A school nurse is preparing an education session on safety for parents of school-age children. What would be an appropriate topic for this age group? providing close supervision to prevent injuries providing drug, alcohol, and sexuality education selecting toys for the developmental level teaching stress reduction techniques

providing drug, alcohol, and sexuality education

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

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

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

"Make sure that you have smoke detectors in your house and that they're in working order."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention? "I will rescue clients from harm before doing anything else." "Only certain members of the healthcare team can extinguish a fire." "I will close the door to the room where the fire is, after clients have been removed." "After clients are evacuated from the room with the fire, the alarm can be sounded."

"Only certain members of the healthcare team can extinguish a fire."

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? "We place our child in a rear-facing car seat in the back seat of the car." "We place our child in a rear-facing car seat in the front of the car." "We place our child in a front-facing car seat in the front of the car." "We place our child in a front-facing car seat in the back seat of the car."

"We place our child in a front-facing car seat in the back seat of the car."

The nurse is teaching a group of older adults at an assisted living facility about age related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?

"are you able to hear the tornado sirens in your area?"

The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1 year old grandchild. Which comment by the grandparent will cause the nurse to intervene?

"if my grandchild eats a plant, I should provide syrup of ipecac"

The nurse is discussing about threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?

"smoking even at parties is not good for my body"

A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?

"when it is cold outside in the winter, I will use a nonvented furnace"

A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?

remove the restraint

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?

risk for injury

A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?

risk for injury: check on patient every 15 minutes

A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure related accident?

surgical asepsis

A homeless adult presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8 degrees F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?

temperature

The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing?

toddler

A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?

wash hands

The nurse is monitoring for the four categories of risk that have been identified in the healthcare environment. Which examples will alert the nurse that these safety risks are occurring?

wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

Owen is a 15-year-old client who is waking up postoperatively. He became combative and tried to strangle one of the nurses. A support team was called and 4-point restraints were applied in this emergent situation. How soon does a licensed provider need to assess the client and place the restraint order? 15 minutes 4 hours 30 minutes 1 hour

1 hour

The nurse is caring for a client with a latex allergy. When ordering lunch for the client, which food does the nurse cross off of the menu that should not be consumed? handful of walnuts ½ cup of pineapples 3 ounces of chicken 1 medium Banana

1 medium Banana

The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?

65 to 75 degrees F

A confused patient is restless and continues to try to remove his oxygen and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? A. Risk for injury: Prevent harm to patient, use restraints if alternatives fail. B. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter. C. Disturbed body image: Encourage patient to express concerns about body. D. Caregiver role strain: Identify resources to assist with care.

A

A nurse is teaching a community group of school-aged parents about safety. The most important item to prioritize and explain is how to check the proper fit of A. a bicycle helmet. B. swimming goggles. C. soccer shin guards. D. baseball sliding shorts.

A

The nurse is caring for an elderly patient admitted with nausea, vomiting, and diarrhea. Upon completing the health history, which priority concern would require collaboration with social services to address the patient's health care needs? A. The electricity was turned off 2 days ago. B. The water comes from the county water supply. C. A son and family recently moved into the home. D. The home is not furnished with a microwave oven.

A

The nurse is preparing a patient for surgery. The nurse explains that the reason for writing in indelible ink on the surgical site the word "correct" is to A. Distinguish the correct surgical site. B. Label the correct patient. C. Comply with the surgeon's preference. D. Adhere to the correct regulatory standard.

A

5. A girl age 4 years has been admitted to the emergency department after accidently ingesting a cleaning product. Which of the following treatments is most likely appropriate in the immediate treatment of the girl's poisoning? A) Administration of activated charcoal B) Inducing vomiting C) Gastric lavage D) Intravenous rehydration

Ans: A Feedback: Activated charcoal is the most common treatment for many poisonings and is more effective and safe than induced vomiting or gastric lavage. Rehydration is likely necessary, but this does not actively treat the girl's poisoning.

10. What age group is most vulnerable to toxic fumes or asphyxiation? A) Young children B) Adolescents C) Toung adults D) Middle adults

Ans: A Feedback: Most exposure to toxic fumes, such as carbon monoxide, occurs in the home. Young children and older adults are more vulnerable to toxic fumes. Suffocation, or asphyxiation, can occur at any age, but the incidence is greater in children.

The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event?

a surgical sponge is left in the patient's incision

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take?

assess the patient

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care?

deficient knowledge

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient's health care needs?

the electricity was turned off 3 days ago

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint?

the patient continues to remove the nasogastric tube

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed, despite instructions to remain there. Which initial intervention is appropriate? Administer a prescribed dose of lorazepam. Contact the physician for an order to apply a waist restraint. Assess for the need to urinate. Raise the side rails.

Assess for the need to urinate.

The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint? A. The patient refuses to call for help to go to the bathroom. B. The patient continues to remove the nasogastric tube. C. The patient gets confused regarding the time at night. D. The patient does not sleep and continues to ask for items.

B

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?" The client will identify unsafe situations in his or her environment. The client will identify resources for safety information. The client will demonstrate safety measures to prevent falls. The client will establish safety priorities with family members.

The client will demonstrate safety measures to prevent falls.

A client's surgical wound dehisced when a nurse removed the staples before a health care provider order was given. Following root cause analysis, which organizational response is appropriate? Select all that apply. The nurse will be disciplined by an impartial review board. Systems around the documentation of orders will be reviewed. The nurse's actions will be deemed intentionally reckless. The nurse will be found to have committed a human error. The nurse will be sued by the hospital for malpractice

The nurse will be found to have committed a human error. Systems around the documentation of orders will be reviewed.

29. After a client falls out of bed, the nurse completes which of the following? A) Safety event report (incident report) B) Telephone call to hospital's attorney C) Progress note stating event report was completed D) Malpractice report

Ans: A Feedback: An accident or incident that compromises safety in a health care agency requires the completion of a safety event report. This is a confidential document, formerly referred to as an incident report. The safety event report is not a part of the medical record and should not be mentioned in the documentation.

18. Bioterrorism has become a commonly used term. What is the definition of bioterrorism? A) A verbal threat by those wishing to harm specific individuals B) A written threat calculated to produce terror in a family C) The deliberate spread of pathogens into a community D) A worldwide plan to produce illness and injury

Ans: C Feedback: Bioterrorism involves the deliberate spread of pathogenic organisms into a community.

An older adult client has developed diabetic neuropathy. What would be the most important education intervention for the client and family? Keep the environment warmer in winter. Obtain a carbon monoxide detector in the home Reduce the temperature on the water heater. Increase the amount of ventilation in the house.

Reduce the temperature on the water heater. The principles of a safe environment for older adults follow the same general guidelines as those for all ages: comfortable temperature range; adequate clothing; bath water of the right temperature (the setting on the hot water heater may need to be reduced); adequate ventilation; and lighting that allows for safe navigation throughout the house at all times of day. Clients with neuropathy will definitely need the hot water heater temperature reduced.

The nurse is assessing clients for risk factors in the workplace. Which clients would be at risk for injury due to the environment of the workplace? Select all that apply. Nursing assistant who lifts clients in a nursing home Gardener who mows and places fertilizer on lawns Medical records technician who works in a doctor's office Owner of a fitness center who teaches one yoga class a day Worker who operates equipment in an automobile assembly plant

Worker who operates equipment in an automobile assembly plant Gardener who mows and places fertilizer on lawns Nursing assistant who lifts clients in a nursing home

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out a bonfire, what will the nurse identify? class B class C class A no fire extinguisher should be used to attempt to extinguish a bonfire

class A Class A fire extinguishers contain water under pressure and are used for burning paper, wood, and cloth. Other answers are incorrect.

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out a gasoline fire, what will the nurse identify? class A class C class B no fire extinguisher should be used to attempt to extinguish a gasoline fire

class B Class B fire extinguishers contain carbon dioxide and are used to extinguish fires caused by gasoline, oil, paint, grease, and other flammable liquids. Other answers are incorrect.

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out an electrical fire, what will the nurse identify? class B class C No fire extinguisher should be used to attempt to extinguish an electrical fire. class A

class C Class C fire extinguishers contain dry chemicals and are used to extinguish electrical fires.

The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family?

d, e d- discuss with the family steps to take if the seizure does not discontinue e- instruct the family to reorient and reassure the patient after consciousness is regained

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which of the following nursing diagnoses will the nurse add to the patient's plan of care? A. Risk for poisoning B. Deficient knowledge C. Risk for imbalanced body temperature D. Risk for suffocation

B

The patient presents to the clinic with a family member. The family member states that the patient has been wandering around the house and mumbling. What is the first assessment the nurse should do? A. Ask the patient why she has been wandering around the house. B. Introduce self and ask the patient her name. C. Take the patient's blood pressure, pulse, temperature, and respiratory rate. D. Immediately do a complete head-to-toe neurologic assessment.

B

The nurse is discussing with a patient's physician the need for restraint. The nurse indicates that alternatives have been utilized. What behaviors would indicate that the alternatives are working? A. The patient continues to get up from the chair at the nurses' station. B. The patient apologizes for being "such a bother." C. The patient folds three washcloths over and over. D. The sitter leaves the patient alone to go to lunch.

C

The nurse is presenting an educational session on safety for parents of adolescents. The nurse should include which of the following teaching points? A. Adolescents need unsupervised time with friends two to three times a week. B. Parents and friends should teach adolescents how to drive. C. Adolescents need information about the effects of beer on the liver. D. Adolescents need to be reminded to use seatbelts on long trips

C

The nurse knows that four categories of risk have been identified in the health care environment. Which of the following provides the best examples of those risks? A. Tile floors, cold food, scratchy linen, and noisy alarms B. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach C. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly D. Dirty floors, hallways blocked, medication room locked, and alarms set

C

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

C

A nurse making a home visit for a patient living in a high-crime area observes that the apartment building does not have outside lighting. Why is this an important assessment? a. It will make the patient less able to go to social gatherings. b. Nurses in home healthcare are not concerned with safety. c. Although important, this assessment is irrelevant to care. d. Assessment includes risk factors in the home and surrounding environment

D

A patient is very anxious and states, "I am so stressed." Why do these factors affect the patient's safety? a. Stress affects interpersonal relationships b. Stress increases retention of information c. Stress increases concern about hazards d. Stress tends to narrow the attention span

D

An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has been abused. What is legally required of the nurse? a. Refer the caregivers of the toddler to a home health nurse. b. Verbally confront the caregivers about the suspicions. c. Nothing; the nurse has no control over the toddler's home. d. Report suspicions about the abuse to proper authorities.

D

The nurse is caring for a patient with a urinary catheter. After the nurse empties the collection bag and disposes of the urine, the next step is to A. Use alcohol-based gel on hands. B. Wash hands with soap and water. C. Remove eye protection and dispose of in garbage. D. Remove gloves and dispose of in garbage.

D

The older adult client was admitted to the emergency department for accidentally overdosing on a prescribed medication. The client is prescribed several medications that have varying frequencies for administration. The nurse is providing tips to the client to prevent such an occurrence from happening again. What instructions would the nurse provide to the client? SELECT ALL THAT APPLY Request large-print medication labels on each of the prescribed medication bottles. Maintain a list of medications with dosages and frequencies, and share it at each primary care provider visit. Contact the pharmacist or primary care provider about questions regarding medications. Keep discontinued medications in case the health care provider prescribes the medication again. Place pills in a pill dispenser that provides for separate dosing throughout the day.

Place pills in a pill dispenser that provides for separate dosing throughout the day. Maintain a list of medications with dosages and frequencies, and share it at each primary care provider visit. Contact the pharmacist or primary care provider about questions regarding medications. Request large-print medication labels on each of the prescribed medication bottles.

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

Report this sentinel event to the Joint Commission and to relevant state agencies 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.

The nursing supervisor is concerned about excessive use of physical restraints on the unit. What interventions would the nursing supervisor employ to decrease the use of restraints? Select all that apply. Provide classes for the nursing staff about appropriate use of restraints and alternatives to restraints. Obtain additional bed alarms or position-sensitive electronic devices for use as needed. Encourage the nurses to use medications instead of physical restraints. Review and change, if needed, current policies at the agency for adherence to accepted national standards. Evaluate each client who is restrained and consult with the client's nurse about the use of the restraint.

Review and change, if needed, current policies at the agency for adherence to accepted national standards. Provide classes for the nursing staff about appropriate use of restraints and alternatives to restraints. Evaluate each client who is restrained and consult with the client's nurse about the use of the restraint. Obtain additional bed alarms or position-sensitive electronic devices for use as needed.

The nurse is assessing the home of new parents who adopted two siblings, one an infant and the other a toddler 18 months old. The nurse notes the following in the home. The parents have no experience with the Heimlich manuever. The crib slats measure less than 2.375 in (6 cm) apart, and there is a soft pillow in the crib. The parents cut food into small pieces (approximately 1/2 inch in size) for the toddler and supervise mealtimes. What recommendations would the nurse make to the parents to provide for safety from asphyxiation or choking? Select all that apply. Cut food into larger pieces, such as bite size, for the toddler. Replace the crib slats so the openings allow a regular sized soda can to fit through. Continue to supervise mealtimes for the children. Take a layperson's class to learn the Heimlich maneuver. Remove the soft pillow from the crib.

Take a layperson's class to learn the Heimlich maneuver. Remove the soft pillow from the crib. Continue to supervise mealtimes for the children.

The nurse is performing a safety belt fit test for a young client at a well-child check-up. What criteria confirms that the child may sit in the back seat of a vehicle with a lap and shoulder belt in place? The shoulder belt does not lay on the collarbone or shoulder when fastened. The child's feet touch the floor of the car when belted in with the lap and shoulder belt. The seat belt stays low on the hips and is not resting on the soft part of the stomach. The knees do not bend at the edge of the seat when child's back is against vehicle's seat back.

The child's feet touch the floor of the car when belted in with the lap and shoulder belt.

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, the healthcare provider orders chemical restraints. Which treatment does the nurse anticipate? asking the unlicensed assistive personnel (UAP) to sit with the client application of devices that reduce the client's ability to move arms articulating the reason for use of a physical restrictive device to the client's spouse administration of an antipsychotic agent to alter the client's behavior

administration of an antipsychotic agent to alter the client's behavior

A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for self care?

b, d, e b- healthcare provider writes the type and location of the restraint d- healthcare provider performs a face to face assessment prior to the order e- healthcare provider specifies the duration and circumstances under which the restraint will be used

The surgical nurse is preparing a client for surgery on the left leg. The client is awake, alert, and oriented. Who does the nurse identify that should mark the leg that will undergo the surgical procedure? (Select all that apply.) nurse surgeon client family member unlicensed assistive personnel

nurse surgeon client

A home health nurse is assessing a family's home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up?

plastic grocery bags are neatly stored under the counter

The staff at a day-surgery clinic are meeting because there have been two significant medication errors committed over the past few weeks. In order to prevent future medication errors, what is the priority action for the nurse's to take? have each medication administered checked and co-signed by another nurse. collaborate with the health care providers to determine whether clients are being prescribed any nonessential medications. cluster the timing of medication administration to reduce the number of times that a client is given medications. take measures to ensure that nurses are not disturbed when obtaining and administering medications

take measures to ensure that nurses are not disturbed when obtaining and administering medications Distraction is a major cause of medication errors. In general, it is not necessary to have two nurses co-administer medications in order for them to be given safely. Performing a medication reconciliation with physicians may reveal that some medications are non-essential, but this does little to enhance overall medication safety. Clustering the administration of medications does not equate with improved safety and reduction of errors.

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? providing a sleep agent to help the client rest instead of pulling IV lines and the catheter temporary application of devices that reduce the client's ability to move arms delegating to the unlicensed assistive personnel (UAP) to sit with the client administration of an antipsychotic agent to alter the client's behavior

temporary application of devices that reduce the client's ability to move arms If diversion behaviors and chemical (drug) restraints have failed, the nurse anticipates that the provider may order temporary application of devices to reduce the client's ability to move arms, which will prevent the behavior. The other actions are not appropriate, so the nurse would not anticipate them.

A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?

uses medication bar coding when administering medications

31. A nurse is assessing a client who recently had a stroke. What is one area of assessment necessary to promote safety? A) Neuromuscular B) Respiratory C) Gastrointestinal D) Genitourinary

Ans: A Feedback: Anything that affects a patient's health state potentially can affect the safety of the environment. For example, a nurse who is assessing a patient with a recent stroke would assess neuromuscular impairment to prevent falls.

The nurse preceptor recognizes the new nurse's ability to determine patient safety risks when which behavior is observed? A. Checking patient identification once every shift B. Multitasking by gathering two patients' medications C. Disposing of used needles in a red needle container D. Raising all four side rails per family request

C

An elderly woman in a long-term care facility has fallen and sustained several injuries. Which of her injuries would be the most serious fall-related injury? a. Lacerated lip b. Thigh contusion c. Fractured ulna d. Fractured hip

D

A nurse is using the QSEN competency of evidence-based practice when caring for clients. What is an example of this competency? The nurse uses computer-generated care plans for client care. The nurse works with other health care team members to provide care for a client diagnosed with Alzheimer's disease. The nurse researches best current practices for prevention of the spread of infection in physician offices. The nurse manager holds an in-service for staff to teach them the safe operation of a new piece of equipment.

The nurse researches best current practices for prevention of the spread of infection in physician offices.

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

The nurse researches new technological advances in the treatment of cancer.

An anxious son asks the nurse how he can keep his older adult father safe in his home. He tells the nurse that his father lives alone, has chronic illnesses, and also has sensory-perceptual alterations. What is the best statement by the nurse? "Put some blocks on his Internet service so he cannot subscribe to disreputable websites." "A good idea is to get a weekly medicine tray at the pharmacy. This will keep him from missing medication doses or taking the wrong pill by accident." "Small, thick area rugs provide lower extremity warmth in cold weather. He may have temperature deficits in his feet." "If you tried hiding his car keys and he keeps finding them, why don't you disconnect the car battery?"

"A good idea is to get a weekly medicine tray at the pharmacy. This will keep him from missing medication doses or taking the wrong pill by accident."

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

"Always provide close supervision for young children when they are in or around pools and bathtubs."

30. The nurse knows that a health care facility should determine its disaster-preparedness plan for delivering care in the event of an emergency or disaster? A) As soon as the disaster is announced publicly B) When officially informed that a disaster has occurred C) After the first disaster has been experienced D) In advance of a possible emergency or disaster

Ans: D Feedback: Each health care facility should determine in advance how to deliver care, if an emergency or disaster occurs. This involves collaboration with internal committees and external agencies.

17. In what situation would the use of side rails not be considered a restraint? A) The nurse keeps them raised at all times. B) The institution's policies mandate using side rails. C) A visitor requests their use. D) A client requests they be up at night.

Ans: D Feedback: It is now recognized that side rails can pose serious risks for some clients. However, side rails are not considered restraints if the client requests they be put up at night to increase feelings of security while asleep. Agency policies help nurses determine when to apply restraints and what type to use.

15. Nurses provide many interventions to prevent falls in health care settings. Which of the following would be an appropriate intervention to prevent falls? A) Keep bed in the high position. B) Keep side rails up at all times. C) Apply restraints to all confused clients. D) Lock wheels on beds and wheelchairs.

Ans: D Feedback: Locking wheels on beds and wheelchairs prevents them from rolling and precipitating a fall. Beds should be kept in low positions with the side rails down in most situations; restraints should be applied only as a last resort.

12. An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has been abused. What is legally required of the nurse? A) Nothing; the nurse has no control over the toddler's home. B) Refer the caregivers of the toddler to a home health nurse. C) Verbally confront the caregivers about the suspicions. D) Report suspicions about the abuse to proper authorities

Ans: D Feedback: Nurses are both legally and ethically obligated to report abuse, either suspected or confirmed. In many states, the failure to report actual or suspected abuse is a crime. The role of the nurse does not include confrontation.

7. A client is very anxious and states, "I am so stressed." Why do these factors affect the client's safety? A) Stress increases retention of information B) Stress affects interpersonal relationships C) Stress increases concern about hazards D) Stress tends to narrow the attention span

Ans: D Feedback: Stressful situations tend to narrow a person's attention span and make him or her more prone to accidents. Stress does not increase retention of information or concern about hazards. Although stress may affect interpersonal relationships, that is not the same as safety.

A patient with an intravenous infusion requests a new gown after bathing. Which of the following actions is most appropriate? A. Disconnect the intravenous tubing, thread the end through the sleeve of the old gown and through the sleeve of the new gown, and reconnect. B. Thread the intravenous bag and tubing through the sleeve of the old gown and through the sleeve of the new gown without disconnecting. C. Inform the patient that a new gown is not an option while receiving an intravenous infusion in the hospital. D. Call the charge nurse for assistance because linen use is monitored and this is not a common procedure.

B

An elderly patient presents to the hospital with a history of falls, confusion, and stroke. The nurse determines that the patient is at high risk for falls. Which of the following interventions is most appropriate for the nurse to take? A. Place the patient in restraints. B. Lock beds and wheelchairs when transferring. C. Place a bath mat outside the tub. D. Silence fall alert alarm upon request of family

B

The nurse has been called to a hospital room where a patient is using a hair dryer from home. The patient has received an electrical shock from the dryer. The patient is unconscious and is not breathing. What is the best next step? A. Ask the family to leave the room. B. Check for a pulse. C. Begin compressions. D. Defibrillate the patient.

B

Elder abuse includes physical abuse, emotional abuse, neglect, and financial abuse. Which of the following are possible signs/symptoms of abuse? Select all that apply a. missing objects or money b. increased appetite c. becoming withdrawn d. increased social interaction e. symmetrical bruises f. behavior changes

B, C, and E

A nurse is administering a scheduled medication to a client using the institution's bar code system. The nurse has scanned the client's armband as well as the scheduled medication. The system has signaled a discrepancy between the dose ordered and the dose scanned. What is the nurse's most appropriate response? Document the discrepancy and place the medication on hold until the next scheduled dose. Consult with a colleague and identify the source of the error signal before proceeding. Consult the client's medication orders and then administer the dose originally poured. Administer the dose specified by the computer system and document the event.

Consult with a colleague and identify the source of the error signal before proceeding.

A client who was receiving care on a psychiatric unit committed suicide at a time when nurses are known to be handing off to nurses on the next shift. What is a responsibility of the organization when responding to this sentinel event? Report the event to the Joint Commission. Appropriately discipline the nurses who were participating in the shift change. Change the institution's policies regarding supervision of clients. Inform local health care institutions about the event in order to promote safety.

Report the event to the Joint Commission.

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

identifying systemic factors on the unit that may have contributed to the event

The nurse is caring for four clients. Which does the nurse anticipate may have a latex sensitivity? 21-year old who cannot eat bananas 43-year old who avoids nuts due to diverticulitis 55-year old who does not drink orange juice due to gastroesophageal reflux disease (GERD) 30-year old who is lactose intolerant

21-year old who cannot eat bananas. The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes. The nurse will anticipate that the client who cannot eat bananas may have a latex sensitivity

A nurse is providing care for a client whose blood pressure has been gradually dropping over the course of a shift. The nurse has decided to inform the client's primary care provider by telephone using the SBAR tool. The nurse will end this communication by: reviewing the main events that she has described to the care provider. making a suggestion about what she believes to be the best action. describing the main assessment results that have been gathered during the shift. identifying the desired outcomes.

making a suggestion about what she believes to be the best action. In the SBAR tool, the "R" denotes a recommendation, not a review. Assessment results are shared earlier. The desired outcomes are not necessarily part of the recommendation.

The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working?

the patient folds three washcloths over and over

When making rounds the nurse observes a purple wristband on a patient's wrist. How will the nurse interpret this finding?

the patient has do not resuscitate preferences

During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?

the patient takes a hypnotic

The nurse has placed a yellow armband on a 70 year old patient. Which observation by the nurse will indicate the patient has an understanding of this action?

the patient wears the red nonslip footwear

Which activity will cause the nurse to monitor for equipment related accidents?

uses a patient controlled analgesic pump

The health department is reviewing community health initiatives for the year. During the summer, the health department focuses infection control activities on which program? delivering fans to older adult residents administering free antibiotics using pesticides for mosquitoes administering influenza immunizations

using pesticides for mosquitoes

Equipment-related accidents are risks in the health care agency. The nurse assesses for this risk when using A. Sequential compression devices. B. A measuring device that measures urine. C. Computer-based documentation. D. A manual medication-dispensing device

A

In which situation would the use of side rails not be considered a restraint? a. A patient requests they be up at night to help with bed mobility. b. The nurse keeps them raised at all times. c. A visitor requests their use. d. The institution's policies mandate using side rails.

A

The nurse is instructing the student nurse regarding discharge teaching and medications. Which response by the student would indicate that learning has occurred? A. "I need to be precise when teaching a patient about Zyprexa (olanzapine) and Zyrtec (cetirizine)." B. "The medications can be picked up at the pharmacy on the way out of the hospital." C. "I need to be sure to give the patient leftover medications from the medication drawer." D. "I need to remember to teach the patient to take all medications at the same time of the day."

A

The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes. Which question would be the most important to ask this group? A. "Are you able to hear the tornado sirens in your area?" B. "Are you able to read your favorite book?" C. "Are you able to remember the name of the person you just met?" D. "Are you able to open a jar of pickles?"

A

The patient has been diagnosed with a respiratory illness and complains of shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. What is the usual comfort range for most patients? A. 65° F to 75° F B. 60° F to 75° F C. 15° C to 17° C D. 25° C to 28° C

A

Which action directly addresses one of the Joint Commission 2015 Hospital National Safety Goals? A long term care facility has put new measures in place to identify residents who may be aggressive. A hospital has set ambitious targets for reducing the incidence of catheter-related urinary tract infections. A public health agency has changed its policies so that two nurses are always present during a home visit. A nurse has committed to exceeding the required amount of continuing education required for license renewal.

A hospital has set ambitious targets for reducing the incidence of catheter-related urinary tract infections.

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 rear-facing safety seat should be used for infants younger than 1 year old and weighing more than 20 lb (9 kg). A rear-facing safety seat should be used for infants younger than 1 year old or up to the maximum weight for the seat. 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). 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.

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.

22. When educating parents of preschoolers, what is most important to include in your presentation? A) Use wrist guards with rollerblades B) Teach preschoolers to tread water C) Keep chemicals in a locked cabinet D) Strict discipline with potty training

Ans: C Feedback: Increasing mobility, lack of life experience and judgment, and immature musculoskeletal and neurologic systems lead to potentially hazardous encounters for toddlers and preschoolers.

20. What statement by a client would indicate that a nurse had successfully implemented a educating/learning strategy to prevent injury in the home? A) "I will turn off the outside lights and lock the doors every night." B) "Do you think it would be best for me to buy a gun?" C) "I am going to remove all those throw rugs on the floor." D) "Well, I always let the boys play in the bathtub; they love it."

Ans: C Feedback: Nurses must evaluate the effectiveness of their interventions to promote safety and prevent injury. If the expected client outcomes have been met and evaluative criteria satisfied, the client should be able to correctly identify real and potential unsafe environmental situations, and implement safety measures in the environment.

25. A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which of the following is a prudent nursing intervention for this client? A) Briefly leave the client in order to call the primary physician to assess the client's condition. B) Order x-rays or CT scans for the client, as needed. C) Document the incident, assessment, and interventions in the client's medical record. D) Do not file an event report unless the client is seriously injured in the fall.

Ans: C Feedback: The nurse is responsible for documenting the incident in the client's record. Assess the patient immediately and provide appropriate care and interventions based on client status, and ensure prompt follow-through for any physician orders for diagnostic tests. An event report should be filed in the case of a fall, as per facility policy.

21. A nurse is caring for a stable toddler diagnosed with accidental poisoning, due to the ingestion of cleaning solution. What must be included in educating parents about how to protect a toddler from accidental poisoning? A) Closely monitor the toddler's activity. B) Label poisonous solutions. C) Keep cleaning solutions locked up. D) Do not leave the toddler alone.

Ans: C Feedback: The parents should keep cleaning solutions locked up to protect the toddler from accidental poisoning. Accidental poisonings usually occur among toddlers and commonly involve substances located in bathrooms or kitchens. Labeling poisonous substances may not help as toddlers are unable to read. Not leaving the child alone and closely monitoring the child are important, but not feasible all the time.

9. Which of the following people has the greatest risk for accidental injury? A) An infant just learning to crawl B) An older adult who walks two miles a day C) An athlete who exercises on a regular basis D) A worker who operates industrial machines

Ans: D Feedback: Certain occupations, lifestyles, and environments place people in more hazardous situations. A worker who operates industrial machines is at greater risk for accidental injury as well as for hearing loss.

A patient with type 1 diabetes has impaired sensation in her lower extremities. What teaching would be necessary to reduce her risk of injury? a. "Always test the temperature of bath water before stepping in." b. "Take your insulin twice a day as we have discussed." c. "Rub lotion on the skin of your legs and feet twice a day." d. "Remember to follow your diet so you lose weight this month."

A

3. A nurse is admitting a client to a geriatric medicine unit following the client's recent diagnosis of acute renal failure. Which of the following nursing actions is most likely to reduce the client's chance of experiencing a fall while on the unit? A) Orient the client to the room and environment thoroughly upon admission. B) Provide the client with a bedpan to reduce the need to transfer to a commode or washroom. C) Administer pain medications sparingly in order to minimize cognitive or musculoskeletal side effects. D) Place the client in a shared room with a client who is stable and oriented.

Ans: A Feedback: A person who is familiar with his or her surroundings is less likely to experience an accidental injury. As part of the hospital admission routine, it is important to orient the client to the safety features and equipment in the room. A bedpan should not be used for the sole reason of reducing the risk of falls, and pain medication should be provided in doses sufficient to treat the client's pain. A client should never be charged with supervising the safety of another client.

8. A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury? A) "Always test the temperature of bath water before stepping in." B) "Take your insulin twice a day as we have discussed." C) "Remember to follow your diet so you lose weight this month." D) "Rub lotion on the skin of your legs and feet twice a day."

Ans: A Feedback: Alterations in sensory perception can have a serious effect on safety. A client whose tactile sense is impaired may not perceive temperature extremes that are a threat to safety. Although all the other statements may be necessary, they do not promote safety.

19. A client arrives at the emergency department with nausea, hematemesis, fever, abdominal pain, and severe diarrhea. There is a suspicion the client has been exposed to the anthrax bacillus. What category of medications will be administered? A) Antimicrobials B) Narcotics C) Antihistamines D) Antacids

Ans: A Feedback: Anthrax is a potentially fatal bacterial infection. The recommended treatment for exposure to, as well as symptoms of, an anthrax infection is with rapid administration of antimicrobial therapy. Narcotics are administered to manage pain. Antihistamines are prescribed to manage allergy conditions. Antacids are prescribed to manage gastrointestinal disorders.

1. The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which of the following topics for staff education is most likely to benefit the greatest number of residents? A) Educating nurses on how to prevent falls B) Reviewing safe medication administration C) Educating nurses on how to prevent wandering by confused residents D) Reviewing resuscitation for cardiac and respiratory arrest

Ans: A Feedback: Falls remain the leading cause of death among older adult Americans. Education that aims to reduce the incidence of falls is likely to be of more benefit than measures that address medication administration, prevention of wandering, or resuscitation procedures, even though such topics may be of importance.

2. Which of the following measures should nurses implement in a hospital setting in order to identify intimate partner violence (IPV)? A) Routine screening of newly admitted clients B) Focused physical assessment for IPV for all new clients C) Involvement of a social worker in the admission assessment of all new female clients D) Review of the definition and legal repercussions of IPV with all new female clients

Ans: A Feedback: Practices related to the identification of IPV vary, but it is generally agreed that a simple screening tool can be an effective strategy. A focused physical assessment and the involvement of social work are not warranted for all clients. A review of the definition and repercussions of IPV is likely not as effective as a simple and direct screening tool.

6. In light of the failure of alternatives, a nurse has been forced to physically restrain an agitated client. Which of the following actions should the nurse perform when applying and maintaining the restraints? A) Tie the client's hand restraint to the bed frame rather than the side rail. B) Obtain a physician's order for the restraints within 24 hours. C) Ensure the client is under continuous surveillance while restrained. D) Choose a restraint device that best minimizes the client's mobility.

Ans: A Feedback: Restraints should be tied to the frame of the bed rather than to the side rails. A physician's order is needed for restraints, except in emergencies when an order must be obtained within one hour of application. Frequent assessment of the client is needed, but continuous surveillance is not necessarily required. The least restrictive type of device that allows the greatest mobility, while still ensuring safety, is chosen.

24. The nurse is caring for a client who has prescribed extremity restraints. The nurse is required to document which of the following? A) Alternative measures attempted before applying the restraints B) A verbal order for renewal of the restraints every 48 hours C) Detailed description of the restraint application process D) Type of personal protective equipment (PPE) used by the nurse during restraint application

Ans: A Feedback: This is not typically documented.

4. Which of the following clients is most likely to face an increased risk of falls due to his or her medication regimen? A) A female client age 77 years who has received a benzodiazepine to minimize her anxiety B) A male client age 79 years whose recent high blood pressure has required a PRN dose of an angiotensin-converting enzyme (ACE) inhibitor C) A woman age 81 years who has required a blood transfusion to treat a gastrointestinal bleed D) A man 90 years of age whose venous ulcer has required the administration of intravenous antibiotics

Ans: A Feedback: While all drugs carry some risk of adverse effects, the use of benzodiazepines and antiepileptics are more predicative of falls than are other drug families.

26. A doctor orders restraints for an older adult client who is disoriented from the pain medication she is taking. Which of the following is an appropriate guideline for applying these restraints? A) Chemical restraints should be tried before using physical restraints. B) The restraints can be ordered by the nursing supervisor in emergency situations. C) The client's vital signs must be assessed every hour. D) Adults must be reassessed within 4 hours; children age 9 to 17 years within two hours; and children under 9 years within one hour.

Ans: D Feedback: Client with restraints must be monitored and reassessed as described in answer D. Restraints must be ordered by a physician, and client vital signs must be assessed every two hours.

32. A nurse specializes in caring for victims of domestic violence. Which of the following statements accurately describes domestic violence in the United States? (Select all that apply.) A) Studies indicate that each year, more than 12 million adults in the United States are victims of intimate partner violence. B) Intimate partner violence is domestic violence or battering between two people in a close relationship. C) Many men who batter their spouses also batter their children. D) There is no evidence linking childhood sexual abuse to adult physical symptoms or substance abuse. E) Domestic violence is not seen in a cycle.

Ans: A, B, C Feedback: Studies indicate that each year, more than 12 million adults in the United States are victims of intimate partner violence. Intimate partner violence is domestic violence or battering between two people in a close relationship. Many men who batter their spouses also batter their children. Recent evidence suggests a relationship between childhood sexual abuse and certain physical symptoms in adulthood, such as gastrointestinal symptoms, eating disorders, and substance abuse. The nurse may be involved directly in health education and counseling measures, or may suggest other resources to the family as additional support for safety, well-being and to interrupt the cycle of violence.

28. Which of the following populations, based on their development stage, would benefit from strategies to prevent falls? Select all that apply. A) Newborns B) Toddlers C) Adolescents D) Adults E) Older Adults

Ans: A, B, E Feedback: Educate parents never to leave newborns alone on a changing table, and also teach parents of toddlers to childproof the home. Parents of preschoolers should make sure their children wear proper safety equipment when riding bicycles or scooters. Adolescents and adults are not at high risk for falls. Older adults, however, are at risk for falls due to the effects of aging on the body systems.

35. The nurse conducting a community emergency preparedness education class includes which of the following as an example of a natural disaster? A) Toxic spill B) Earthquake C) War D) Terrorist event

Ans: B Feedback: A disaster is broadly defined as a tragic event of great magnitude that requires the response of people outside the involved community. Disasters can be categorized as natural (e.g., massive flooding following a hurricane or an earthquake) or man-made (e.g., a toxic spill, war, or a terrorist event).

13. A grade school nurse is addressing parents at a PTA meeting regarding car safety. Which of the following is a recommended safety guideline for this age group? A) All school-age children need to be secured in safety seats. B) Booster seats should be used for children until they are 4 feet 9 inches tall or at least 8 years of age. C) Children under 8 years old should ride in the back seat. D) All school-age children need to be secured in lap seat belts.

Ans: B Feedback: All school-age children need to be secured in safety seats, belt-positioning booster seats, or shoulder lap belts for their size. The National Highway Traffic Safety Administration recommends booster seats for children until they are 4 feet 9 inches tall or at least 8 years of age, and all children 12 and under should ride in the back seat to eliminate the risk of injury from airbag deployment (National Highway Traffic Safety Administration [NHTSA], 2008).

14. An adolescent has recently had a ring inserted into her navel. Which of the following is the greatest risk facing the adolescent as a result of this activity? A) A scar over the navel B) A local and/or systemic infection C) A greater acceptance by peers D) A strained relationship with parents

Ans: B Feedback: Body piercing is a quick procedure that does not require anesthesia, but the risk for infection is great. This risk includes local infection, hepatitis B virus, and HIV.

34. Which of the following nursing diagnoses would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub? A) Noncompliance B) Risk for Suffocation C) Risk for Falls D) Risk for Imbalanced Body Temperature

Ans: B Feedback: Death from drowning occurs from suffocation. Nearly half of all drowning victims are children under the age of 5. Most drowning deaths in young children occur because of inadequate supervision of a bathtub or pool.

27. A physician orders restraints for a confused client who is at risk for injury by pulling out tubes necessary to sustain her life. Which of the following statements describes an accurate action to take when applying these restraints? A) Apply restraints to the hands or wrists, never to the ankles. B) Ensure that two fingers can be inserted between the restraint and the client's extremity. C) Use a quick-release knot to tie the restraint to the side rail. D) Remove the restraint at least every four hours, or according to agency policy.

Ans: B Feedback: 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 two hours.

33. Prior to inserting a nasogastric tube, the nurse correctly verifies the client's identity through which of the following methods? A) Ask the client: "Is your name___?" B) Check the client's identification bracelet. C) Verify the client's room number. D) Call the client by his or her first name.

Ans: B Feedback: The Joint Commission's National Patient Safety Goals include improving the accuracy of client identification. The nurse should check the client's identification bracelet to verify the client's identity.

16. A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out? A) Place it in the client's medical record. B) Take it home and keep it locked up. C) Maintain it according to agency policy. D) Include it with documentation of the error.

Ans: C Feedback: An accident in a health care agency requires filling out an incident report, a confidential document that objectively describes the circumstances of the accident. The incident report is not a part of the medical record and should not be mentioned in the documentation. The report is maintained by the agency.

23. The facility risk management team is preparing an in-service to nursing staff members. The presentation will highlight risk factor increase related directly to the type of clientele on a nursing unit. The presenter will correctly explain that which of the following risks is increased for female nurses who work on an oncology care unit? A) Back injuries B) Bloodborne pathogens C) Adverse reproduction D) Neurologic disorders

Ans: C Feedback: Common risks in health care facilities are exposure to bloodborne pathogens from stick injuries via used needles, back injuries caused by heavy lifting, and potential adverse reproductive outcomes as a result of overexposure to antineoplastic medications. On oncology divisions, the nurse is continually exposed to antineoplastic agents.

The nurse is assessing a client's mental health competence and decision-making ability. Which activity will best provide the needed information to the nurse? Ask the client to read and discuss a passage from a pamphlet. Discuss with the client's family any concerns about his mental stability. Ask the client to review his medical health history to assess for the level of organization of his thought processes. Ask the client "what if" questions to determine level of thought organization.

Ask the client "what if" questions to determine level of thought organization. When revewing mental health and level of decision-making ability, the best method is to ask the client "what if" type of questions. Assessing the client's reading ability and understanding of passages read will not provide the needed information. Asking the client to discuss his medical history will provide some information but will not provide information on his ability to reason and make clear decisions. Questioning the family provides only a secondary source of information and will not be as effective.

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? Document the observed behaviors in the client's chart. Report the suspicions to to the authorities. Ask to examine the client alone in order to speak to her privately. Nothing, as it is none of the nurse's concern.

Ask to examine the client alone in order to speak to her privately.

A nurse is assessing a patient who recently had a stroke. What is one area of assessment necessary to promote safety? a. Abdominal integrity b. Neuromuscular status c. Hygiene d. Skin integrity

B

The emergency department has been notified of a potential bioterrorist attack. The nurse assigned to the department realizes that the most important task for safety in this situation is to A. Carry out the role and responsibilities of the nurse quickly and efficiently. B. Cluster all patients with the same symptoms to a specific part of the department. C. Determine the biologic agent and manage all patients using Standard Precautions. D. Prepare for post-traumatic stress associated with this bioterrorist attack

C

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. Immediately, the nurse assigns a nursing diagnosis of risk for injury with a goal for the patient to be safe. Which of the following actions should the nurse take first? A. Activate the alarm. B. Extinguish the fire. C. Remove the patient. D. Confine the fire.

C

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous infusion. The nurse begins to develop a plan to care for the patient. Which nursing intervention should take priority?\ A. Gather restraint supplies. B. Try alternatives to restraint. C. Assess the patient. D. Call the physician for a restraint order

C

The nurse is completing discharge education for the patient regarding home medications. Which patient behavior is an indication that the patient understands the directions regarding the antibiotic medication? A. The patient nods throughout the educational session. B. The patient reads the medication prescription out loud. C. The patient states, "I will finish the antibiotic in ten days." D. The patient asks where to get the prescription filled.

C

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. Pad bony prominences. Choose the most restrictive type of device that allows the least amount of mobility. 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. Remove the restraint at least every 2 hours or according to agency policy and client need. Fasten the restraint to the side rail. Check agency policy for the application of restraints and secure a physician's order.

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

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? Abdominal pain and hematemesis Cough, dyspnea, and fatigue Ulcerated skin lesions Nausea, vomiting, and diarrhea

Cough, dyspnea, and fatigue 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.

A patient has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include A. Encouraging visitors in the early evening. B. Placing all four side rails in the "up" position. C. Checking on the patient once a shift. D. Placing a high risk for falls armband on the patient.

D

Nurses provide many interventions to prevent falls in healthcare settings. Which of the following would be an appropriate fall-prevention intervention? a. Apply restraints to all confused patients. b. Keep side rails up at all times. c. Keep bed in the high position. d. Lock wheels on beds and wheelchairs.

D

The nurse discussed threats to adult safety with a college group. Which of the following statements would indicate understanding of the topic? A. "Our campus is safe; we leave our dorms unlocked all the time." B. "As long as I have only two drinks, I can still be the designated driver." C. "I am young, so I can work nights and go to school with 2 hours' sleep." D. "I guess smoking even at parties is not good for my body."

D

The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to A. Learning to walk. B. Trying to pull up on furniture. C. Being dropped by a caregiver. D. Growing ability to explore and oral activity.

D

The older patient presents to the emergency department after stepping in front of a car at a crosswalk. After the patient has been triaged, the nurse interviews the patient. Which of the following comments would require follow-up by the nurse? A. "I try to exercise, so I walk that block almost every day." B. "I waited and stepped out when the traffic sign said go." C. "The car was going too fast, the speed limit is 20." D. "I was so surprised; I didn't see or hear the car coming."

D

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. These data would help to support a nursing diagnosis of A. Risk for poisoning. B. Knowledge deficit. C. Impaired home maintenance. D. Risk for injury.

D

Which of the following are examples of developmental risk factors? Select all that apply. a. A 42-year-old woman is unable to move her left side following a stroke. b. A teenager has difficulty ambulating following multiple fractures from a MVA. c. A sales executive worries that he won't make his yearly sales quota. d. A toddler is allowed to crawl in a house that has not been childproof. e. An elderly woman in a long-term healthcare facility is at high risk for falls. f. A machinist works in an environment that exposes him to loud noises.

D and E

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? Flush the eyes with a cool saline solution for a 10-minute period. Advise the client to avoid blinking until after the eyes are irrigated. Flush the eyes with water for 10 minutes. Wash the eyes with a hypertonic solution for at least 30 minutes.

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.

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

Open doors and windows.

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

Peer pressure causes children of this age to task risks. Peer pressure causes children of this age to task 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.

The nurse is educating parents of toddlers on how to prevent injuries and promote safety for their children. What are age-appropriate safety interventions for this age group? Select all that apply. Provide drug, alcohol, and sexuality education. Do not leave the child alone in the bathtub or near water. Supervise the child closely to prevent injury. Childproof the house to ensure that poisonous products and small objects are out of reach. Practice emergency evacuation measures with the child. Instruct the child to wear proper safety equipment when riding bicycles or scooters.

Supervise the child closely to prevent injury. Childproof the house to ensure that poisonous products and small objects are out of reach. Do not leave the child alone in the bathtub or near water.

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

The client will identify behaviors that would decrease the risk for injury.

Which nursing assessment finding while screening a family with an 11-month-old infant who is beginning to pull himself up to stand should be most concerning? The mother loves to drink coffee all day. The father of the infant smokes outside of the house. The older siblings play ball in a backyard that is not fenced in. They have not purchased a helmet for the child to wear when he begins riding his tricycle.

The mother loves to drink coffee all day. As infants begin to become mobile and more active, they have the tendency to pull up on objects and climb on furniture because they are curious. Since this 11-month-old is becoming mobile and is pulling up, the risk is great that he may pull over a cup of the mother's hot coffee that she drinks all day. Therefore, this should be concerning to the nurse. The father who smokes does so outside. This child is not able to ride a tricycle yet if he is just pulling up, so the parents have time to purchase a helmet. The older siblings in the backyard have no direct affect on this child yet. When he gets older and begins to run and play, the risk of running after the stray ball from the backyard becomes a concern.

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

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

A nurse follows the universal client compact principles for partnership when providing care for clients. Which nursing action reflects this philosophy? The nurse does not allow the client to review his or her own medical information. The nurse confers with members of the health care team but does not ask for family input from the assigned advocate of the client. The nurse makes health care decisions for a client who is uncooperative. The nurse includes the client as a member of the health care team.

The nurse includes the client as a member of the health care team.

A team of inner city school nurses attends a community conference on child safety during the summer months. What would be the priority health outcome that these nurses would expect to achieve in summer school? The students will only swim in the community pool when it hasn't rained for two days. The students will read 400 pages from the summer book list. The students will sign up for fall afterschool programs. The students will demonstrate proper use of safety equipment while playing sports.

The students will demonstrate proper use of safety equipment while playing sports.

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

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

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

Toileting 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.

A 14-year-old boy is in the clinic for his well-child exam. When the client asks his mother if she has any questions for the practitioner, she states "He sleeps so much. I am worried about how lazy he is." What does the nurse know to be true about sleep in adolescents? Increased sleep guarantees adolescents will behave in a safe manner. Trying to balance too many activities can result in sleep deprivation. Increased sleep is the result of boredom. Adolescents require less sleep than adults; this is clearly an underlying medical concern.

Trying to balance too many activities can result in sleep deprivation.

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply. Use 3-prong electric plugs whenever possible. Only operate equipment the nurse is familiar with. Twist or bend electric cords to make sure the cords are not dragging on the floor. Clean all equipment with soap and water after use. Use equipment only for the use for which it was intended.

Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with. Use 3-prong electric plugs whenever possible.

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

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 nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient?

a, b, c, d a- where did you fall? b- what time did the fall occur? c- what were you doing when you fell? d- what types of injuries occurred after the fall?

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene?

a, c, d a- smoking in bed helps me relax and fall asleep c- we use the same space heater as my grandparents used d- we use the RACE method when using the fire extinguisher

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one?

a. 2, 1, 4, 3 2- remove the patient 1- pull the alarm 4- close doors and windows 3- use the fire extinguisher

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

administering medications to the client 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.

The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session?

b, c, e b- walk to the mailbox in the summer c- encourage yearly eye examinations e- keep pathways clutter free

The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care?

b, c, e, f b- patient is placed on bilateral wrist restraints at 0815 c- bilateral radial pulses present, 2+, hands warm to touch e- attempts to distract the patient with television are unsuccessful f- released from restraints, active range-of-motion exercises completed

An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient?

backs wheelchair into elevator, leading with large rear wheels first

A client is being treated for community-acquired pneumonia and has experienced respiratory distress and hypoxia on several occasions since being admitted. The nurse can best prevent adverse outcomes during this client's care by: collaborating closely with members of the interdisciplinary team. educating the client about self-care as it relates to respiratory health. vigilantly monitoring the client's oxygenation status. involving the client when identifying goals for care.

vigilantly monitoring the client's oxygenation status. All of the listed actions are appropriate to the care of this client. However, close monitoring and early detection of changes are paramount in the prevention of adverse outcomes. Frequent and careful assessment is a priority.