Chapter 27 Safety, Security, & Emergency Preparedness

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? 1. Ask to examine the client alone in order to speak to her privately. 2. Report the suspicions to to the authorities. 3. Nothing, as it is none of the nurse's concern. 4. Document the observed behaviors in the client's chart.

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

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order? 1. Ensure that two fingers can be inserted between the restraint and the client's extremity. 2. Apply restraints to the hands or wrists, never to the ankles. 3. Use a quick-release knot to tie the restraint to the side rail. 4. Remove the restraint at least every 4 hours, or according to facility policy.

1. Ensure that two fingers can be inserted between the restraint and the client's extremity.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply. 1. Headache 2. Increased thirst 3. Drowsiness 4. Fever 5. Vomiting

1. Headache 3. Drowsiness 5. Vomiting

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected the client with an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident? 1. Report this sentinel event to the Joint Commission and to relevant state agencies 2. Inform the public that the incident occurred, while protecting the confidentiality of the clients. 3. Offer compensation to the affected client in a timely manner, while maintaining the client's confidentiality. 4. File an incident report with the American Nurses Association describing plans for preventing similar events in the future.

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

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? 1. Take the restraints off, stay with her, and talk gently to her. 2. Talk with the client's family about taking her home because she is out of control. 3. Leave the restraints on and talk with her, explaining that she must calm down. 4. Sedate her with sleeping pills and leave the restraints on.

1. Take the restraints off, stay with her, and talk gently to her.

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply. 1. Takes furosemide daily 2. Admits to drinking wine through the evening 3. Shares a one floor living space with a spouse 4. Participates in a walking club 5. Has history of diabetic neuropathy

1. Takes furosemide daily 2. Admits to drinking wine through the evening 5. Has history of diabetic neuropathy

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? 1. The child's feet touch the floor of the car when belted in with the lap and shoulder belt. 2. The shoulder belt does not lay on the collarbone or shoulder when fastened. 3. The seat belt stays low on the hips and is not resting on the soft part of the stomach. 4. The knees do not bend at the edge of the seat when child's back is against vehicle's seat back.

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

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client? 1. The client will not experience a fall and remains free of injury. 2. The client will stay in bed. 3. The client will not ambulate without assistance. 4. The client will wear nonskid footwear

1. The client will not experience a fall and remains free of injury.

Which Knowledge, Skills, and Attitudes (KSAs) are nursing actions based on the QSEN competency of quality improvement? Select all that apply. 1. The nurse schedules a meeting with the nurse manager to review and update the policies for client admissions. 2. The nurse administrator sets up a committee to review the procedure manual and recommend any needed changes. 3. The nurse coordinator calls a meeting of all the health care professionals involved in the care of a client. 4. The nurse uses the Internet to find new nursing techniques for the care of a client with cystic fibrosis. 5. The nurse manager schedules a meeting of staff to review client outcomes on the hospital ward. 6. The nurse listens to a client who is having trouble adjusting to a long-term care facility and treats the client with compassion and respect.

1. The nurse schedules a meeting with the nurse manager to review and update the policies for client admissions. 2. The nurse administrator sets up a committee to review the procedure manual and recommend any needed changes. 5. The nurse manager schedules a meeting of staff to review client outcomes on the hospital ward.

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group? 1. Use protective sporting equipment. 2. Use caution when descending stairs. 3. Do not text while driving. 4. Be cautious of electrical outlets.

1. Use protective sporting equipment.

The residential home nurse is caring for a client who lives in an assisted living unit. In designing a plan of care to prevent fires, the nurse identifies which as the highest risk to the client? 1. gas stove 2. cigarette smoking 3. clothes dryer 4. electrical sockets

1. gas stove

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? 1. "We place our child in a rear-facing car seat in the back seat of the car." 2. "We place our child in a front-facing car seat in the back seat of the car." 3. "We place our child in a front-facing car seat in the front of the car." 4. "We place our child in a rear-facing car seat in the front of the car."

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

Which nurse would be at the highest risk of causing a hazardous situation? 1. A nurse who is transferred to another unit to assist with care 2. A nurse who has worked 32 hours of overtime this week 3. A nurse who has placed a client in the bed with three side rails up 4. A nurse who is administering medications to four clients

2. A nurse who has worked 32 hours of overtime this week

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home? 1. Use the stairs in the new home. 2. Clear clutter in the walkways of the new home. 3. Change the older adult's routine. 4. Take walks outside.

2. Clear clutter in the walkways of the new home.

A nurse is teaching parents about Internet safety for children. Which actions are recommended guidelines for Internet use? Select all that apply. 1. Emphasize that everything read online is usually true. 2. Investigate any public chat rooms used by the children. 3. Use filtering software to block objectionable information. 4. Keep identifying information posted on the web sites. 5. Be alert for downloaded files with suffixes that indicate images or pictures.

2. Investigate any public chat rooms used by the children. 3. Use filtering software to block objectionable information. 5. Be alert for downloaded files with suffixes that indicate images or pictures.

What is the primary role of the nurse in the care of clients who experience domestic violence? 1. Calling the police 2. Providing prompt recognition of the potential or actual threat to safety 3. Identifying health education and counseling measures for the family 4. Serving as a witness in court

2. Providing prompt recognition of the potential or actual threat to safety

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? 1. The nurse should await results of the x-ray before filing the report. 2. The nurse should record the incident in the client's medical record and fill out a safety event report separately. 3. The nurse should make a copy of the safety event report and place it in the client's medical record. 4. The nurse should include a note on the client's chart that mentions the report.

2. The nurse should record the incident in the client's medical record and fill out a safety event report separately.

A nurse on a medical unit recognizes the need to demonstrate Quality and Safety Education for Nurses (QSEN) competencies in clinical practice. Which action best demonstrates the skills necessary to meet the QSEN competency of safety? 1. filling out an incident report accurately after a client went missing from the unit 2. understanding the functions of a new automated intravenous pump that has been introduced to the unit 3. appreciating the relationship between continuing education and client safety 4. valuing the contributions of clients and their families who suggest possible improvements in care

2. understanding the functions of a new automated intravenous pump that has been introduced to the unit

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for a 9-month-old infant? 1. "We place our baby in a front-facing car seat in the middle of the back seat of the car." 2. "We place our baby in a rear-facing car seat in the front of the car so that we can see him in case he chokes." 3. "We place our baby in a rear-facing car seat in the back seat of the car." 4. "We place our baby in a front-facing car seat in the front of the car so that he doesn't cry."

3. "We place our baby in a rear-facing car seat in the back seat of the car."

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following? 1. Alert the local fire department. 2. Attempt to extinguish the fire. 3. Activate the fire alarm and notify the appropriate person. 4. Answer all telephone calls and call bells.

3. Activate the fire alarm and notify the appropriate person.

What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household? 1. Educate about, and be aware of, signs of risky behaviors. 2. Teach seat belt safety. 3. Avoid stuffed animals and blankets in the crib. 4. Include safeguards to prevent falls in the home.

3. Avoid stuffed animals and blankets in the crib.

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment? 1. Provide a pamphlet on maintaining healthy sleep habits 2. Suggest a high-fiber, low-fat diet 3. Encourage exercise that improves balance and muscle strength 4. Restrict consumption of liquids before bedtime

3. Encourage exercise that improves balance and muscle strength

One of the leading causes of death in the United States is drowning. nition How can the nurse assist in lowering this statistic? 1. Begin swim lessons with toddlers. 2. Require fencing around all pools. 3. Implement drowning prevention strategies. 4. Educate children in cardiopulmonary resuscitation.

3. Implement drowning prevention strategies.

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should: 1. hold a facility-wide meeting to identify strategies for making improvements to the safety of residents. 2. document strategies in the client's health record for preventing future incidents. 3. fill out an incident report, with the goal of preventing a similar event in the future. 4. complete an incident report to determine who was primarily responsible for the event.

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

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? 1. "Never keep firearms in the home with young children." 2. "Never smoke in the bed in the house when young children are present." 3. "Store medications in a locked area to prevent children from getting into them." 4. "Always provide close supervision for young children when they are in or around pools and bathtubs."

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

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse? 1. Administer the client's sedative as ordered. 2. Put up all four side rails on the bed. 3. Contact the physician for a restraint order. 4. Initiate use of a bed alarm.

4. Initiate use of a bed alarm.

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first? 1. Promptly document the change in client status 2. Apply limb restraints to ensure client safety 3. Leave to notify the health care provider concerning a change in client status 4. Reduce distressing environmental stimuli to maximize client safety

4. Reduce distressing environmental stimuli to maximize client safety

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action? 1. Activate the fire alarm. 2. Close the client's door. 3. Obtain the fire extinguisher. 4. Remove the client from the room.

4. Remove the client from the room.

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use? 1. 19-year-old male college student majoring in physics 2. 34-year-old male who does not use a seat belt 3. 40-year-old female who is working two jobs 4. 25-year-old female who just accepted her first job

1. 19-year-old male college student majoring in physics

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. 1. Communication ability 2. Type of health care facility 3. Community population 4. Developmental level 5. Mobility

1. Communication ability 4. Developmental level 5. Mobility

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply. 1. Teamwork and collaboration 2. Client-centered care 3. Establishment of clinical career ladders 4. Revamping the licensing requirements for foreign-educated nurses 5. Quality improvement (QI)

1. Teamwork and collaboration 2. Client-centered care 5. Quality improvement (QI)

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? 1. The hospital must bear any costs incurred for treating the client's injury. 2. CMS will bear the hospital's costs if the client chooses to sue the hospital. 3. The hospital will be fined by CMS because the client developed a pressure injury. 4. CMS may choose to divert clients to other health care facilities in the future.

1. The hospital must bear any costs incurred for treating the client's injury.

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? 1. "Induce vomiting while you wait for emergency personnel to arrive." 2. "Check breathing and heart rate." 3. "What do you think that the child might have ingested?" 4. "At what time did the child ingest the substance?"

2. "Check breathing and heart rate."

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? 1. side rails 2. a dose of an antipsychotic 3. a geriatric chair with a tray 4. a dose of an analgesic

2. a dose of an antipsychotic

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client? 1. Initiation of a peripheral intravenous (IV) line for fluid administration 2. Evaluation of all of his cranial nerves 3. Assessment of head circumference 4. Assessment of vital signs and respiratory status

4. Assessment of vital signs and respiratory status

A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is of the highest priority? 1. Raise an alarm. 2. Confine the fire. 3. Extinguish the fire. 4. Rescue the client.

4. Rescue the client.

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? 1. ensuring that the client's nurse is held accountable and educated about best practice 2. reinforcing the standards for nursing care to staff members who were involved 3. communicating the potential consequences of the near miss to the client involved 4. identifying systemic factors on the unit that may have contributed to the event

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

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: 1. mass trauma terrorism. 2. bioterrorism. 3. nuclear terrorism. 4. chemical terrorism.

1. mass trauma terrorism.

Which level of health care provider may make the decision to apply physical restraints to a client? 1. nurse practitioner 2. senior personal care assistant 3. RN nurse manager 4. LPN team leader

1. nurse practitioner

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? 1. Leave outlets and switches open so air circulates through them. 2. Refrain from using extension cords. 3. Remove the plug from the wall by pulling the electric cord. 4. All machines that are used infrequently are to remain plugged in.

2. 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? 1. Attempt to extinguish the fire. 2. Rescue anyone who is in immediate danger. 3. Activate the fire alarm on the unit. 4. Evacuate clients and staff.

2. Rescue anyone who is in immediate danger.

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan? 1. Gun safety 2. Fire safety 3. Childproofing the house 4. Smoking cessation

3. Childproofing the house

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? 1. Tape the electrical cord of the pump to the floor. 2. Run the electrical cord of the pump under the carpet. 3. Obtain a three-prong grounded plug adapter. 4. Use an extension cord to provide freedom of movement.

3. Obtain a three-prong grounded plug adapter.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client? 1. Raising all the side rails of the bed 2. Providing a bed that is elevated from the floor 3. Placing the client in a bed with a bed alarm 4. Using restraints on the client to prevent a fall

3. Placing the client in a bed with a bed alarm

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? 1. "Car seats are recommended until children are at least 10 years old." 2. "Car seats are only recommended until children are 3 years old." 3. "Your child will be safe in the car using the provided shoulder harness and lap belts." 4. "At the age of 6 your child should be using a booster seat."

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

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response? 1. "Induce vomiting and call 911 right away." 2. "You should not have left your child alone while you showered." 3. "Did you leave the household chemical in reach of your child?" 4. "Is your child breathing at this time?"

4. "Is your child breathing at this time?"

When performing fall risk assessments, which client does the nurse determine is most at risk for falls? 1. A 60-year-old male with weakness in his left side and slowed reaction time 2. An 80-year-old female with a history of falling last year and breaking a hip 3. A 50-year-old male being cared for in an unfamiliar health care environment 4. A 70-year-old female with postural hypotension who wears eyeglasses, but has no history of falls

4. A 70-year-old female with postural hypotension who wears eyeglasses, but has no history of falls

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should: 1. document strategies in the client's health record for preventing future incidents. 2. hold a facility-wide meeting to identify strategies for making improvements to the safety of residents. 3. complete an incident report to determine who was primarily responsible for the event. 4. fill out an incident report, with the goal of preventing a similar event in the future.

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

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? 1. Conceal IV tubing with gauze wrap 2. Assure bed alarms are activated 3. Request a sedative from health care provider 4. Ask visiting family member to stay

1. Conceal IV tubing with gauze wrap

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. 1. Never text while driving 2. Obey the speed limit. 3. Drive at night when fewer people are on the road. 4. Always wear a seat belt. 5. Limit the number of other adolescents in the car.

1. Never text while driving 2. Obey the speed limit. 4. Always wear a seat belt. 5. Limit the number of other adolescents in the car.

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply. 1. There is spilled water on the floor. 2. The client is wearing the oxygen around the neck. 3. The skin is a bluish-color. 4. The IV is not infusing at the correct rate. 5. The client's television is turned off.

1. There is spilled water on the floor. 2. The client is wearing the oxygen around the neck. 3. The skin is a bluish-color. 4. The IV is not infusing at the correct rate.

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include? 1. Buy protective sporting equipment. 2. Peer pressure causes children of this age to take risks. 3. Place all household cleaners out of reach. 4. Supervise your child on the changing table.

2. Peer pressure causes children of this age to take risks.

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? 1. Wash the eyes with a hypertonic solution for at least 30 minutes. 2. Advise the client to avoid blinking until after the eyes are irrigated. 3. Flush the eyes with water for 10 minutes. 4. Flush the eyes with a cool saline solution for a 10-minute period.

3. Flush the eyes with water for 10 minutes.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take? 1. Extinguish the fire. 2. Evacuate the unit. 3. Pull the fire alarm lever. 4. Confine the fire.

3. Pull the fire alarm lever.

The nurse is teaching the caregiver of an infant about safety. Which teaching will the nurse include? 1. Buy protective sporting equipment. 2. Place all household cleaners out of reach. 3. Supervise your child on the changing table. 4. Peer pressure causes children of this age to take risks.

3. Supervise your child on the changing table.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? 1. A detailed description of the restraint application process 2. The type of personal protective equipment used by the nurse during restraint application 3. The alternative measures attempted before applying the restraints 4. A verbal prescription for the restraints, renewed every 48 hours

3. The alternative measures attempted before applying the restraints

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate? 1. articulating the reason for use of a physical restrictive device to the client's spouse 2. asking the unlicensed assistive personnel (UAP) to sit with the client 3. administration of an antipsychotic agent to alter the client's behavior 4. application of devices that reduce the client's ability to move arms

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

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? 1. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. 2. Respond to the past history of the client (including previous falls) to determine the need for restraints. 3. Individualize the use of restraints and choose the most easily used device. 4. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

4. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.