Foundations Exam 1 // CH 27

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

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

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

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

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. A. Takes furosemide daily B. Has history of diabetic neuropathy C.Admits to drinking wine through the evening D. Participates in a walking club E. Shares a one floor living space with a spouse

A. Takes furosemide daily B. Has history of diabetic neuropathy C.Admits to drinking wine through the evening

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

C. Toileting

The nurse is caring for an older client who is ordered restraints. What is the priority nursing action? A. Offer the client bathroom privileges and assistance B. Secure restraints with paper tape to allow quick removal C. Remove the restraints every six hours to prevent skin breakdown D. Keep arm restraints loose to prevent injury

D. Keep arm restraints loose to prevent injury

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? A. Poor judgment B. Social pressure C. Past experience D. Normal rebellion

B. Social pressure

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

C. inadvertent needlestick.

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: A. bioterrorism. B. chemical terrorism. C. mass trauma terrorism. D. nuclear terrorism.

C. mass trauma terrorism.

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

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

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

D. Rescue anyone who is in immediate danger.

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? A. Petechial hemorrhages B. Skin lesion with local edema that progresses, enlarges, ulcerates, and becomes necrotic C. Flu-like symptoms D. Skeletal muscle paralysis that progresses symmetrically and in a descending manner

D. 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? A. Place the safety event report in the client's medical record for future reference. B. File the safety event report in the appropriate file and document in the nurse's notes the date and time that it was filed. C. Make a copy of the safety event report for the client. D. Submit the safety report to the appropriate department within the facility so that it can be reviewed.

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

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 to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered? A. administration of an antipsychotic agent to alter the client's behavior B. providing a sleep agent to help the client rest instead of pulling IV lines and the catheter C. delegating to the unlicensed assistive personnel (UAP) to sit with the client D. temporary application of devices that reduce the client's ability to move arms

D. temporary application of devices that reduce the client's ability to move arms

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? A. asking the unlicensed assistive personnel (UAP) to sit with the client B. application of devices that reduce the client's ability to move arms C. administration of an antipsychotic agent to alter the client's behavior D. articulating the reason for use of a physical restrictive device to the client's spouse

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

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

A. Encourage exercise that improves balance and muscle strength

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? A. Eighth B. Fifth C. Tenth D. First

B. Fifth

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? A. Put up all four side rails on the bed. B. Contact the physician for a restraint order. C. Initiate use of a bed alarm. D. Administer the client's sedative as ordered.

C. Initiate use of a bed alarm.

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

D. Reduce the temperature on the water heater.

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

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

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

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

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

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

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

A. Supervise your child on the changing table.

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

A. Teamwork and collaboration B. Quality improvement (QI) C. Client-centered care

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

B. Centers for Disease Control and Prevention

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

B. Ensure the parent engages in regular exercise. C. Provide frequent reorientation. E. Increase the parent's social interaction.

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

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

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

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

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan? A. Lock all cabinets that contain cleaning supplies. B. Restrain the baby in a car seat. C. Keep all pots and pans in lower cabinets. D. Give warm bottles of formula to the baby.

B. Restrain the baby in a car seat.

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

B. The client will identify risk-taking behaviors.

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. a dose of an analgesic B. a dose of an antipsychotic C. a geriatric chair with a tray D. side rails

B. a dose of an antipsychotic

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

B. take measures to ensure that nurses are not disturbed when obtaining and administering medications

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

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

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

C. Call for assistance to remove the client from the area.

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? A. Most home fires are caused by children playing with matches. B. Most fatal home fires occur while people are cooking. C. Most people who die in house fires die of smoke inhalation rather than burns. D. About 10% of home fire deaths occur in a home without a smoke detector.

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

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

C. Open doors and windows.

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

C. 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.

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? A. Nausea, vomiting, and diarrhea B. Abdominal pain and hematemesis C. Ulcerated skin lesions D. Cough, dyspnea, and fatigue

D. Cough, dyspnea, and fatigue

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls? A. Allow the client to use the bathroom independently. B. Maintain a high bed position so the client will not attempt to get out unassisted. C. Keep the client sedated with tranquilizers. D. Involve family members in the client's care.

D. Involve family members in the client's care.

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

D. The client will demonstrate safety measures to prevent falls.

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

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

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? A. The nurse should await results of the x-ray before filing the report. B. The nurse should include a note on the client's chart that mentions the report. C. The nurse should make a copy of the safety event report and place it in the client's medical record. D. The nurse should record the incident in the client's medical record and fill out a safety event report separately.

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

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

D. 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.

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? A. No extension cords are being used. B. Machines used infrequently are unplugged. C. Outlets and switches have cover plates. D. A hair dryer is placed next to the sink.

D. A hair dryer is placed next to the sink.

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

A. Use equipment only for the use for which it was intended. C. Use three-pronged electric plugs whenever possible. D. Only operate equipment the nurse is familiar with.

The nurse instructs the family of an older adult client with a visual impairment and decreased mobility that the most common problem for these clients is related to: A. falls. B. electrical cords. C. aspiration. D. medication errors.

A. falls.

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

A. using pesticides for mosquitoes

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

D. "Check breathing and heart rate."

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? A. 30 minutes B. 4 hours C. 15 minutes D. 1 hour

D. 1 hour

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. A. Headache B. Vomiting C. Fever D. Increased thirst E. Drowsiness

A. Headache B. Vomiting E. Drowsiness

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. A. Mobility B. Developmental level C. Communication ability D. Type of health care facility E. Community population

A. Mobility B. Developmental level C. Communication ability

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse? A. Assess the client for signs and symptoms of osteoporosis B. Arrange for a skilled home care assessment C. Perform a vision test with Snellen chart D. Arrange an audiology consult to evaluate hearing

B. Arrange for a skilled home care assessment

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. A. Childproof the house to ensure that poisonous products and small objects are out of reach. B. Do not leave the child alone in the bathtub or near water. C. Instruct the child to wear proper safety equipment when riding bicycles or scooters. D. Provide drug, alcohol, and sexuality education. E. Supervise the child closely to prevent injury. F.Practice emergency evacuation measures with the child.

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

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

A. Conceal IV tubing with gauze wrap

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client? A. "Use the call bell for any needs and wear nonslip footwear." B. "It is important to us that you remain free from injury." C. "Do not get up without assistance for any reason." D. "You will mostly stay in bed while you are hospitalized."

A. "Use the call bell for any needs and wear nonslip footwear."

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

A. A medication regimen that includes diuretics or analgesics places an individual at risk for falls. C. Some people are more at risk for accidents than others. E. A person with a history of falls is likely to fall again.

A new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant? A. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat. B. A rear-facing safety seat should be used for infants younger than 1 year old and weighing more than 20 lb (9 kg). C. A rear-facing safety seat should be used for infants younger than 1 year old or up to the maximum weight for the seat. D. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old and weighing less than 20 lb (9 kg).

A. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat.

Which item would alert the home care nurse to a safety hazard threatening a young child? A. Dangling blind cords B. Padded child safety seat C. Three blankets in a crib D. A gated stairway

A. Dangling blind cords

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

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

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

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

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? A. Placing the client in a bed with a bed alarm B. Providing a bed that is elevated from the floor C. Raising all the side rails of the bed D. Using restraints on the client to prevent a fall

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

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? A. Pull the fire alarm lever. B. Extinguish the fire. C. Evacuate the unit. D. Confine the fire.

A. Pull the fire alarm lever.

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

A. Refrain from using extension cords.

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? A. Take the restraints off, stay with her, and talk gently to her. B. Sedate her with sleeping pills and leave the restraints on. C. Talk with the client's family about taking her home because she is out of control. D. Leave the restraints on and talk with her, explaining that she must calm down.

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

A client has been diagnosed with a glioblastoma and the care team has determined that this brain tumor is inoperable. Which aspects of the the client's subsequent care demonstrate adherence to the Quality and Safety Education for Nurses (QSEN) competencies? Select all that apply. A. The care team balances the best available evidence about glioblastoma treatment with the client's preferences. B. Nurses proactively identify threats to the client's safety that may occur as treatment is provided. C. Treatments are chosen with the goal of minimizing the financial burden on the health care institution. D. Each member of the care team uses the best available technology to organize and provide care. E. The care team meets with the client and family promptly to identify their preferences for treatment.

A. The care team balances the best available evidence about glioblastoma treatment with the client's preferences. B. Nurses proactively identify threats to the client's safety that may occur as treatment is provided. D. Each member of the care team uses the best available technology to organize and provide care. E. The care team meets with the client and family promptly to identify their preferences for treatment.

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

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

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? A. The hospital must bear any costs incurred for treating the client's injury. B. CMS will bear the hospital's costs if the client chooses to sue the hospital. C. The hospital will be fined by CMS because the client developed a pressure injury. D. CMS may choose to divert clients to other health care facilities in the future.

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

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

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

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include? A. Use of blankets, pillows, and stuffed animals in the crib B. correct placement of booster seats for the car C. safety of guns in the home D. the use of skid-proof mats for the bath tub

A. Use of blankets, pillows, and stuffed animals in the crib

The nurse is preparing to give an educational program to parents of toddlers related to promotion of safety. What should the nurse discuss with parents to reduce the risk of injury for this developmental stage? Select all that apply. A. accidental drowning B. electrocution from outlets C. falls from stairs D. ingestion of toxic medicine E. play-related injuries

A. accidental drowning B. electrocution from outlets C. falls from stairs

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: A. fill out an incident report, with the goal of preventing a similar event in the future. B. hold a facility-wide meeting to identify strategies for making improvements to the safety of residents. C. document strategies in the client's health record for preventing future incidents. D. complete an incident report to determine who was primarily responsible for the event.

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

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse? A. the 2-year-old leaning against the screen of a window in a classroom B. the 6-year-old riding a bike on the playground with his friend C. the 2-year-old helping mom to open the front door of the school D. the 2-year-old and 6-year-old each holding the mother's hand

A. the 2-year-old leaning against the screen of a window in a classroom

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety? A. "Young children secured in a bicycle passenger seat do not have to wear a helmet." B. "Parents are effective role models for children when they also wear helmets while riding." C. "The chin strap on the helmet should be adjusted to fit loosely so that it does not choke the child." D. "Any helmet is appropriate for bicycle riding because all children should wear helmets when riding."

B. "Parents are effective role models for children when they also wear helmets while riding."

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? A. Educate about, and be aware of, signs of risky behaviors. B. Avoid stuffed animals and blankets in the crib. C. Teach seat belt safety. D. Include safeguards to prevent falls in the home.

B. Avoid stuffed animals and blankets in the crib.

The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize? A. Notify the organization's leader that a disaster has been called B. Establish the nurse's role during a disaster C. Identify the resources available for the nursing unit D. Provide simple explanations to maximize client safety

B. Establish the nurse's role during a disaster

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure? A. Mummy restraint B. Extremity restraint C. Elbow restraint D. Waist restraint

B. Extremity restraint

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

B. Flush the eyes with water for 10 minutes.

When educating families on fire safety in the home, which information is important for the nurse to emphasize? A. Use extension cords to prevent shock. B. Have a meeting place outside the home in case of fire. C. Keep a fire extinguisher in a closet. D. Account for all members and then exit together.

B. Have a meeting place outside the home in case of fire.

An individual calls the telehealth nurse and reports that a family member was just found on the floor of an enclosed garage while a car was still running. The family member is unconscious and cherry red in color. What direction will the telehealth nurse provide? A. Turn the car's air conditioner on to circulate flow of air. B. Open garage doors and windows, and call 911. C. Instruct the caller to quickly administer oral fluids. D. Direct the caller to search for a carbon monoxide detector in the garage.

B. Open garage doors and windows, and call 911.

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

B. She may be the victim of cyber-bullying.

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

B. The nurse adds the information in the safety event report to the client health record.

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

B. The skin is a bluish-color. C. The IV is not infusing at the correct rate. D. There is spilled water on the floor. D. The client is wearing the oxygen around the neck.

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to: A. falls from staircases. B. automobile accidents. C. falls from beds. D. play-related injuries.

B. automobile accidents.

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

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

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? A. "Induce vomiting and call 911 right away." B. "You should not have left your child alone while you showered." C. "Is your child breathing at this time?" D. "Did you leave the household chemical in reach of your child?"

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

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

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

The older client tells the nurse that the client needs to use the restroom. Which safety intervention must the nurse perform first? A. Offer the bedpan to keep the client safe. B. Ask the unlicensed assistive personnel (UAP) to help the client to the restroom. C. Assess the need for assistance with ambulation. D. Ask a family member to help the client to the restroom.

C. Assess the need for assistance with ambulation.

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? A. Assessment of head circumference B. Evaluation of all of his cranial nerves C. Assessment of vital signs and respiratory status D.Initiation of a peripheral intravenous (IV) line for fluid administration

C. Assessment of vital signs and respiratory status

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? A. Use a quick-release knot to tie the restraint to the side rail. B. Apply restraints to the hands or wrists, never to the ankles. C. Ensure that two fingers can be inserted between the restraint and the client's extremity. D. Remove the restraint at least every 4 hours, or according to facility policy.

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

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

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

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? A. Collaborate with the resident's health care provider to have his or her diuretics discontinued. B. Increase the resident's physical activity to reduce evening restlessness. C. Investigate the possibility of discontinuing his or her catheter. D. Limit the resident's fluid intake in order to reduce his or her urge to void.

C. Investigate the possibility of discontinuing his or her catheter.

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? A. Use an extension cord to provide freedom of movement. B. Run the electrical cord of the pump under the carpet. C. Obtain a three-prong grounded plug adapter. D. Tape the electrical cord of the pump to the floor.

C. Obtain a three-prong grounded plug adapter.

The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply. A. Maintain restraints until discharge. B. Withhold information from family regarding restraints due to HIPAA. C. Obtain order from a licensed provider within minutes of restraint application. D. Check circulation and skin condition every 2 hours. E. Offer regular, frequent opportunities for toileting.

C. Obtain order from a licensed provider within minutes of restraint application. D. Check circulation and skin condition every 2 hours. E. Offer regular, frequent opportunities for toileting.

The nurse is teaching the caregiver of a 3-year-old about safety. Which teaching will the nurse include? A. Peer pressure causes children of this age to take risks. B. Buy protective sporting equipment. C. Place all household cleaners out of reach. D. Supervise your child on the changing table.

C. Place all household cleaners out of reach.

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

C. Reduce distressing environmental stimuli to maximize client safety

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care? A. Risk for Falls related to immobility B. Altered Sensory Perception related to decreased visual acuity C. Risk for Poisoning related to poor eyesight and the inability to read medication labels D. Risk for Injury related to substance use

C. Risk for Poisoning related to poor eyesight and the inability to read medication labels

What generalization can be made about safety in client care? A. Safety is an important need, but not as important as self-actualization. B. Health care providers exclude safety as a client need. 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. Safety is a paramount concern underlying all nursing care.

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

C. The alternative measures attempted before applying the restraints

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

C. administering medications to the client

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states: A. "My child needs a helmet if in a secured passenger bike seat." B. "My child should wear a helmet every time he rides a bike." C. "The helmet should rest 1 in (2.5 cm) above the eyebrows." D. "I should be able to fit two fingers between my chin and the chin strap."

D. "I should be able to fit two fingers between my chin and the chin strap."

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

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

An 8-year-old boy fell off his bicycle. He was not wearing a helmet and has sustained a concussion. What information should the nurse teach the parents about concussions? A. "Try to keep him resting for a few days at home using the television and his video games." B. "Concussions happen often in children of this age group, and they always bounce back fine." C. "Wearing bicycle helmets will keep your child safe from head injuries." D. "It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness."

D. "It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness."

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? A. 25-year-old female who just accepted her first job B. 34-year-old male who does not use a seat belt C. 40-year-old female who is working two jobs D. 19-year-old male college student majoring in physics

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

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? A. Alert the local fire department. B. Attempt to extinguish the fire. C. Answer all telephone calls and call bells. D. Activate the fire alarm and notify the appropriate person.

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

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

D. Childproofing the house

The nurse considers applying restraints to an agitated client. Which action should the nurse take first? A. Call a family member to come and sit with the client. B. Assess the client for existing injuries to the wrists and hands. C. Ensure the client cannot reach any objects in the room. D. Dim the lights and speak softly about something the client enjoys.

D. Dim the lights and speak softly about something the client enjoys.

What best describes the nurse's role in disaster preparedness? A. Administration of all of the medications B. Counseling the victims and families C. Performance of all of the skills such as IV insertion and wound care D. Multiple roles, including triage and the distribution of resources

D. Multiple roles, including triage and the distribution of resources

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

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

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls? A. Accompany the client to the bathroom every 4 hours around the clock. B. Obtain an order for insertion of an indwelling urinary catheter. C. Limit the client's fluid intake during the evening. D. Provide a bedside commode and ensure adequate lighting.

D. Provide a bedside commode and ensure adequate lighting.

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

D. Report the event to the Joint Commission.

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care? A. Chronic Confusion Related to Long-Standing Alcohol Use B. Noncompliance Related to Medication Regimen C. Impaired Bed Mobility Related to Muscle Wasting D. Risk for Injury Related to Agitation

D. Risk for Injury Related to Agitation

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? A. The nurse should request permission from the client to photograph the bruises. B. The nurse should notify the primary care physician about the bruises. C. The nurse should contact the facility's social services department. D. The nurse should question the client about the source of the bruises.

D. The nurse should question the client about the source of the bruises.

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

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

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: A. peeling paint and easy access to the backyard pool. B. risky behaviors and cyberbullying. C. household cleaners stored under the sink and hanging cords on window blinds. D. polypharmacy and use of multiple extension cords.

D. polypharmacy and use of multiple extension cords.

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? A. places bed at lowest setting B. clears a path from bed to bathroom C. has client sit in bed for a few moments before standing D. provides slippers for ambulation

D. provides slippers for ambulation