Fundamentals Ch. 27 Safety, security and emergency prepardness

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

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

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

a dose of an antipsychotic

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

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

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? the 2-year-old helping mom to open the front door of the school the 2-year-old and 6-year-old each holding the mother's hand the 6-year-old riding a bike on the playground with his friend the 2-year-old leaning against the screen of a window in a classroom

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

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. Fires are responsible for most hospital incidents. A medication regimen that includes diuretics or analgesics places an individual at risk for falls. A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. A nurse whose behavior is reasonable and prudent, and similar to what would be expected of another nurse in a similar circumstance, is still likely to be found liable if a client falls, especially if an injury results. Between 15% and 25% of falls result in fractures or soft tissue injury.

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

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

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

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

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

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

A hair dryer is placed next to the sink.

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

A nurse who has worked 32 hours of overtime this week

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

Admits to drinking wine through the evening Takes furosemide daily Has history of diabetic neuropathy

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? Arrange furniture so that the client has something to hold on to. Assess the need for assistance with ambulation. Apply socks to the client's feet. Put the client's bedside rails up.

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 priorityassessment when the nurse first sees the client? Assessment of head circumference Initiation of a peripheral intravenous (IV) line for fluid administration Assessment of vital signs and respiratory status Evaluation of all of his cranial nerves

Assessment of vital signs and respiratory status

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning? Allow the child to swim with friends. Monitor the activities of the toddler. Instruct the toddler not to go near the pool. Avoid unattended baths for the toddler.

Avoid unattended baths for the toddler.

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

Dangling blind cords

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

Flush the eyes with water for 10 minutes.

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

Multiple roles, including triage and the distribution of resources

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

Peer pressure causes children of this age to take risks.

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

Rescue anyone who is in immediate danger.

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? Risk for Injury Related to Agitation Impaired Bed Mobility Related to Muscle Wasting Noncompliance Related to Medication Regimen Chronic Confusion Related to Long-Standing Alcohol Use

Risk for Injury Related to Agitation

The nurse is caring for a young child in the hospital who is being discharged home with his grandmother, who has guardianship. When performing a risk assessment, the nurse identifies that his grandmother has one other adult living with her to help with the child, because the grandmother has congestive heart failure and diabetes mellitus. In addition, the financial situation is poor and she cannot afford to buy safety devices to safety-proof the house. What nursing diagnosis is most appropriate for this child based on these findings? Risk for Injury related to substance use Risk for Contamination related to flaking or peeling of paint Risk for Suffocation related to child left unattended in the bathtub Risk for Poisoning related to medications in unlocked cabinets

Risk for Poisoning related to medications in unlocked cabinets

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? Altered Sensory Perception related to decreased visual acuity Risk for Falls related to immobility Risk for Injury related to substance use Risk for Poisoning related to poor eyesight and the inability to read medication labels

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

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

The alternative measures attempted before applying the restraints

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

The client will demonstrate safety measures to prevent falls.

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

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

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? The nurse should contact the facility's social services department. The nurse should notify the primary care physician about the bruises. The nurse should question the client about the source of the bruises. The nurse should request permission from the client to photograph the bruises.

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

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

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? Respond to the past history of the client (including previous falls) to determine the need for restraints. Individualize the use of restraints and choose the most easily used device. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. 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.

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 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. Vomiting Headache Increased thirst Drowsiness Fever

Vomiting Headache Drowsiness

An older adult woman in a long-term care facility has fallen and sustained a hip fracture. The nurse would ask which question(s) to assess possible causes of the fall? Select all that apply. "Did you attempt to get up without the assistance of staff?" "Can you tell what you were doing before you fell?" "Is it possible you may have tripped over a rug or a cord?" "Did you experience dizziness prior to the fall?" "Did you have pain in your hip prior to the fall?"

"Can you tell what you were doing before you fell?" "Is it possible you may have tripped over a rug or a cord?" "Did you experience dizziness prior to the fall?" "Did you have pain in your hip prior to the fall?"

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

"Check breathing and heart rate."

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

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

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

"Is your child breathing at this time?"

The nurse is assessing an adolescent with an annual physical. The parent reports noticing a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The parent does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse? "Let's admit your child to an acute care facility so that we can run more tests." "This is typical adolescent behavior. Ignore it and it will improve." "Adolescents are generally difficult children. Sometimes punishment is necessary to make them change their attitudes." "These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial."

"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial."

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

Implement drowning prevention strategies.

A nurse is volunteering in a free community health clinic. One of the services offered is vehicle restraint checks for children. Which principles apply to infant and child restraints? Select all that apply. Infants should be rear-facing up to the age of 2 years. A child may sit in the front seat when 8 years old Booster seats should be used until the child is 4 ft 9 in (145 cm) tall. Children over 30 lb (13.5 kg) only need a lap and shoulder belt. Infants should remain in the infant seat until the age of 2 years.

Infants should be rear-facing up to the age of 2 years. Booster seats should be used until the child is 4 ft 9 in (145 cm) tall.

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

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

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

Obtain a three-prong grounded plug adapter.

The nurse is caring for a client who has been placed in physical restraints. Which nursing action is appropriate? Select all that apply. Continue using the restraints until discharge. Obtain a physician order 2 hours after restraints are applied. Offer opportunities for toileting frequently and regularly. Check circulation and skin condition frequently and regularly. Communicate with the family regarding the need for restraints.

Offer opportunities for toileting frequently and regularly. Check circulation and skin condition frequently and regularly. Communicate with the family regarding the need for restraints.

A nurse is placing an infant in a mummy restraint to perform eye care. Which is a recommended guideline for application of a mummy restraint? Secure the blanket under the child's body on each side by tucking it in instead of using safety pins. Place the child on the blanket, with the edge of the blanket at or above neck level. Leave the lower part of the blanket open and pull the sides of the blanket over the child's body. Position the child's left arm alongside the body and pull the right side of the blanket over the shoulder and chest.

Place the child on the blanket, with the edge of the blanket at or above neck level.

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 priorityrecommendation for this client? Providing a bed that is elevated from the floor Raising all the side rails of the bed Using restraints on the client to prevent a fall Placing the client in a bed with a bed alarm

Placing the client in a bed with a bed alarm

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock? Refrain from using extension cords. All machines that are used infrequently are to remain plugged in. Remove the plug from the wall by pulling the electric cord. Leave outlets and switches open so air circulates through them.

Refrain from using extension cords.

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

Social pressure

The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include? Peer pressure causes children of this age to take risks. Buy protective sporting equipment. Supervise your child on the changing table. Keep medications out of reach.

Supervise your child on the changing table.

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

Initiate use of a bed alarm.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home? Most people who die in house fires die of smoke inhalation rather than burns. About 10% of home fire deaths occur in a home without a smoke detector. Most fatal home fires occur while people are cooking. Most home fires are caused by children playing with matches.

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

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

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

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: play-related injuries. falls from staircases. falls from beds. automobile accidents.

automobile accidents.

The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include: peeling paint and easy access to the backyard pool. polypharmacy and use of multiple extension cords. household cleaners stored under the sink and hanging cords on window blinds. risky behaviors and cyberbullying.

polypharmacy and use of multiple extension cords.