Chapter 27: Patient Safety and Quality Chapter 28: Immobility

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 with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the nurse use to help prevent injury secondary to this rotation?

A trochanter roll

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

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

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."

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? 1. Pull the alarm. 2. Remove the patient. 3. Use the fire extinguisher. 4. Close doors and windows.

2, 1, 4, 3

The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one? 1. Grasp the drawsheet firmly near the patient. 2. Move the patient and drawsheet to the desired position. 3. Position one nurse at each side of the bed. 4. Place the drawsheet under the patient from shoulder to thigh. 5. Place your feet apart with a forward-backward stance. 6. Flex knees and hips and on count of three shift weight from the front to back leg

3, 4, 1, 5, 6, 2

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° F

Which patient will the nurse see first?

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

The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?

A foot cradle

Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan?

A patient who is not completely immobile

A nurse is providing care to a group of patients. Which patient will the nurse see first?

A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea

A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care?

A patient with neck surgery

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

Increased aggressiveness and blood spots on clothing may indicate substance abuse.

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 the teaching session?

Proper fit of a bicycle helmet

A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient?

Altered nutrient metabolism

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

Applying the restraint

The nurse is caring for a patient who has had a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive ROM will be initiated. When should the nurse begin this therapy?

As soon as the ability to move is lost

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 nurse is preparing to lift a patient. Which action will the nurse take first?

Assess weight and determine assistance needs.

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Whichpriority action will the nurse take?

Assist the patient with comfort measures.

The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient?

Assist with ambulation and measure how far the patient walks.

The patient is being admitted to the neurological unit with a diagnosis of stroke. When will the nurse begin discharge planning?

At the time of admission

The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take when assessing the respiratory system?

Auscultate the entire lung region to assess lung sounds.

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent?

Back

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 nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?

Blood pressure cuff

The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding?

Both feet are supported on the floor with ankles flexed.

A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel?

Changing the patient's position

A nurse is evaluating care of an immobilized patient. Which action will the nurse take?

Compare the patient's actual outcomes with the outcomes in the care plan.

Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?

Consults physical therapy for strengthening exercises in the extremities

The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?

Dangle the patient at the bedside.

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

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.

A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?

Each movement is moved just to the point of resistance by the nurse.

The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?

Encourage the patient to perform as many self-care activities as possible.

Assist the patient with comfort measures.

Establish goals that are measurable and realistic.

The nurse is admitting a patient who has been diagnosed as having had a stroke. The health care provider writes orders for "ROM as needed." What should the nurse do next?

Further assess the patient.

The nurse is observing the way a patient walks. Which aspect is the nurse assessing?

Gait

The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend?

High protein, high calorie

A nurse is assessing pressure points in a patient placed in the Sims' position. Which areas will the nurse observe?

Ileum, clavicle, knees

A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?

Imbalance

A patient is admitted and is placed on fall 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 nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use?

Lateral position

A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse consider?

Loss of hope

The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?

Low-molecular-weight heparin doses

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

Manage all patients using standard precautions.

The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the nurse take?

Measure the calf circumference of both legs.

A nurse is caring for a patient with osteoporosis and lactose intolerance. What will the nurse do?

Monitor intake of vitamin D.

A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?

Moves patient's arm until thumb is upward and lateral to head with elbow flexed

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

A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?

Patient is lying on side.

The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

Place pillow under the patient's abdomen after turning.

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.

A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse's action?

Prevention of joint contractures

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.

A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?

Renal calculi

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

Temperature

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.

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

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 health care 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

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 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 goal is most appropriate for a patient who has had a total hip replacement?

The patient will walk 100 feet using a walker by the time of discharge.

A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal?

When observed laterally, the spinal curves align in a reversed "S" pattern.

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? (Select all that apply.)

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.

A nurse is assessing body alignment. What is the nurse monitoring?

The relationship of one body part to another while in different positions

The nurse is caring for an older-adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings?

These are common manifestation with UTIs.

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

Toddler

The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe?

Use a friction-reducing device.

A nurse is assessing the skin of an immobilized patient. What will the nurse do?

Use a standardized tool such as the Braden Scale.

The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the nurse use for logrolling?

Use at least three people.

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

Uses a patient-controlled analgesic pump

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? (Select all that apply.)

a. Close all doors. b. Note evacuation routes. c. Note oxygen shut-offs. d. Move bedridden patients in their bed

Upon assessment a nurse discovers that a patient has erythema. Which actions will the nurse take? (Select all that apply.)

a. Consult a dietitian. d. Increase frequency of turning. e. Place on pressure-relieving mattress.

The nurse is caring for a patient who has had a recent stroke and is paralyzed on the left side. The patient has no respiratory or cardiac issues but cannot walk. The patient cannot button a shirt and cannot feed self due to being left-handed and becomes frustrated very easily. The patient has been eating very little and has lost 2 lbs. The patient asks the nurse, "How can I go home like this? I'm not getting better." Which health care team members will the nurse need to consult? (Select all that apply.)

a. Dietitian b. Physical therapist e. Occupational therapist f. Psychologist

The nurse is caring for a patient with impaired physical mobility. Which potential complications will the nurse monitor for in this patient? (Select all that apply.)

a. Footdrop c. Hypostatic pneumonia d. Impaired skin integrity

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.)

a. Smoking in bed helps me relax and fall asleep. c. We use the same space heater my grandparents used. d. We use the RACE method when using the fire extinguisher.

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? (Select all that apply.)

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 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 safe care? (Select all that apply.)

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

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? (Select all that apply.)

b. Patient is placed in 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

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? (Select all that apply.)

b. Walk to the mailbox in the summer. c. Encourage yearly eye examinations. e. Keep pathways clutter free.