Chapter 19: Safety

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?

1 hour

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?

Assess for the need to urinate.

A nurse finds that a fire has broken out in a client's room at the health care facility. Place the steps the nurse should take in the correct sequence, from first to last.

Evacuate the client. Raise an alarm. Confine the fire. Extinguish the fire.

A nurse finds a client in his room asphyxiated with carbon monoxide (CO) inhalation. Which activity should be the priority for the nurse?

Get the victim out of the present environment.

Which statement should the nurse include in the education plan regarding safety issues for a group of adult clients?

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

A nurse is assigned to care for a 10 month-old boy. Which activity should be the priority for the nurse?

Protect the toddler from injury.

Which nursing diagnosis would be appropriate for educational interventions for a single mother who leaves her toddler unattended in the bathtub?

Risk for Suffocation

A nurse is assisting a client who has been poisoned. The substance is non-caustic medication. Place the steps the nurse will take in caring for this client in the correct sequence.

Verify that the client is alert. Induce vomiting. Give activated charcoal. Administer a laxative.

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?

a dose of an antipsychotic

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 water for 10 minutes.

An older adult 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?

Fractured hip

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers

Which agent has the potential to affect the integrity of latex gloves?

oil-based lotions

A nurse has attended a fire safety training program for the facility. The nurse demonstrates understanding of how to prioritize actions during a fire by doing the actions listed below. Place the actions in the sequence that would best demonstrate the nurse's understanding.

removing the client from immediate danger pulling the alarm and calling 'code red' closing all the doors and windows evacuating the clients if directed

There is a fire in the neurology unit of a health care facility. What would be most appropriate to avoid in this situation?

use of elevators

A nurse is working as an industrial nurse. Which activity would the nurse suggest that the employers adopt to prevent carbon monoxide (CO) inhalation by the workers?

using carbon monoxide detectors and alarms

A nurse is providing instructions to the mother of a toddler regarding the prevention of burn injuries in the toddler. Which instruction is the priority to provide to the mother?

Keep coffee cups on the counter above the child's reach.

A nurse is attending to an adolescent client at the health care facility who has sprained an ankle during a soccer match. What is the most common reason for an adolescent to risk injury?

Peer pressure

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

Refrain from using extension cords.

A nurse 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?

Rescue anyone who is in immediate danger.

RACE

Rescue, Activate alarm, Confine the fire, Evacuate/Extinguish

The nurse is reviewing a healthcare provider's orders in the electronic health record (EHR) and notices several abbreviations. What is the appropriate nursing action?

Contact healthcare provider to clarify order.

The surgical nurse is preparing a client for surgery on the left leg. Which nursing action is appropriate? (Select all that apply.)

Mark the appropriate lower extremity as the one intended for surgery. Have the client mark the body part intended for surgery. Go through a preprocedure verification protocol. Call for a "time out" immediately before surgery begins.

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

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

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls?

provides slippers for ambulation

A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury?

"Always test the temperature of bath water before stepping in."

Which topics should be included in an education plan for preventing falls in the home? Select all that apply.

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 nurse caring for a confused client who is not allowed to get out of bed asks the physician for an order for restraints. Which of the following are guidelines for the use of restraints on clients? Select all that apply.

The client's family must be involved in the decision and plan of care. Alternatives to restraints and less restrictive interventions must have been implemented and failed. The benefit gained from using a restraint must outweigh the known risks for that client

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?

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