FUNDAMENTALS CHAPTER 10: SAFETY

The nurse is considering the use of an SRD to prevent a patient from self-injury. When using an SRD, what would the nurse do? Select all that apply. 1. Obtain an order from the HCP for the SRD. 2. Explain the purpose of the SRD to the patient. 3. Explain the purpose of the SRD to the family. 4. Obtain consensus of nursing staff for type of SRD. 5. Exhaust all alternatives before using an SRD.

1, 2, 3, 5

The nurse is conducting a fall risk assessment on an older adult patient who is moving into an assisted living center. Which questions would the nurse ask? Select all that apply. 1. "Have you had any falls in the past year?" 2. "Are you able to independently get up after a fall?" 3. "Do you feel unsteady when you stand up?" 4. "Are you able to independently walk from room to room?" 5. "What medications are you taking?" 6. "Do you use a cane or other assistive device?"

1, 3, 4, 5, 6

The older adult residents in a nursing home must be evacuated because the facility is at risk for flooding and damage due to a hurricane that will pass through the area in several days. The nurse is assigned to keep a log to document the events. Which information is most important to record? Select all that apply. 1. How each resident was transported 2. Names of residents 3. Where the residents were sent 4. What personal belongings were sent 5. Who transported each resident 6. Notification of family members and health care providers (HCPs)

1, 2, 3, 5, 6

The nurse is planning to teach a community group about fire safety in the home. Which information would be included in the presentation? Select all that apply. 1. No smoking by the patient, family, or visitors in areas where oxygen is used. 2. Use safety matches to light candles or fireplaces. 3. Install fire alarms, smoke detectors, and carbon monoxide detectors. 4. Practice fire escape routes from each room and practice exit drills. 5. Use one electrical circuit to facilitate the monitoring of cords and appliances. 6. Cover electrical cords with a secure carpet to prevent falls

1, 3, 4

The hospitalized patient is confused and has a history of falls. Which actions would the nurse take to help avoid the use of SRDs? Select all that apply. 1. Review the patient's medication list. 2. Assign the patient to a quiet room far from the nurses' station. 3. Use a sitter if needed if family members are not available. 4. Use a bed alarm. 5. Restrict visitors because the patient becomes upset when they leave. 6. Use relaxation techniques such as massage or music to create a calm atmosphere for the patient.

1, 3, 4, 6

The nurse is teaching a new group of UAP how to evacuate residents from a long-term care facility in case of a fire or other emergency. Which item would be needed for the universal carry method? 1. A blanket 2. A wheelchair 3. A stretcher 4. A mechanical lift

1. A blanket

In the event of a mercury spill, what is the priority nursing action? 1. Evacuate everyone from the room 2. Close the interior doors and open windows 3. Vacuum the mercury and glass shards 4. Mop the floor with hot water and soup

1. Evacuate everyone from the room

The nurse is working in a local health department and has noted an unusually large number of phone calls about food-borne illness. Which question is the nurse most likely to ask callers to differentiate the possible involvement of the bio-terrorist agent that causes botulism from other more common causes of food-borne illness? 1. In addition to gastrointestinal symptoms, have you had drooping eyelids or difficulty swallowing or speaking? 2. Have you experienced a low-grade fever, sweating, fatigue, and a nonproductive cough? 3. How soon after eating did the abdominal cramping, vomiting, and diarrhea start? 4. Have you had fever, malaise, and muscle aches with a rash on the tongue, mouth, throat, and palms?

1. In addition to gastrointestinal symptoms, have you had drooping eyelids or difficulty swallowing or speaking? --> Botulism presents with gastrointes- tinal symptoms, followed by neurologic symp- toms; there is no fever, or change in mental status or sensory perception.

A patient begins to have a grand mal seizure. What is the priority action? 1. Monitor the patency of the airway. 2. Protect against falls and other injuries. 3. Suction the mouth to prevent aspiration. 4. Gently insert an oral airway between the teeth.

1. Monitor the patency of the airway.

14. An older adult patient in a long-term care facility has been wandering around outside of the room during the late evening hours. The patient has a history of falls. How would the nurse intervene? 1. Obtain an order for a bed and chair alarm. 2. Keep the light on and play the television all night. 3. Put up the side rails and frequently check on the patient. 4. Have the family come to check on the patient at night.

1. Obtain an order for a bed and chair alarm.

Which occurrence is most likely to be investigated as a "sentinel event"? 1. Patient leaves the hospital against medical advice because she gets angry with the nurse. 2. An older patient sustains a broken arm related to the use of an SRD. 3. A nurse is 2 hours late administering a routine scheduled medication. 4. During a follow-up phone call, a patient reports that care in the hospital was poor.

2. An older patient sustains a broken arm related to the use of an SRD.

The nurse is reviewing the disaster preparedness plan for a small nursing home. What would be included in the plan? Select all that apply. 1. Emergency treatment for the most critically injured 2. Possible admission to a hospital or transfer to a temporary shelter 3. Log to document residents' names and locations 4. System to notify families and providers 5. Designation of an area for decontamination 6. Method of patient identification, such as a bracelet or picture ID

2, 3, 4, 6

The patient reports dizziness when standing up too fast. Which over-the-counter medication is most likely to be contributing to the patient's orthostatic hypotension? 1. Non-aspirin pain reliever 2. Antihistamine 3. Vitamin supplement 4. Medicated cough drop

2. Antihistamine --> antihistamines cause drowsiness

Before the nurse can intervene, the UAP pushes contaminated material into an overfilled sharps container and sustains a puncture wound. What would the nurse do first? 1. Tell the UAP to immediately report to the infection-control nurse. 2. Assist the UAP to scrub the wound with copious amounts of soap and water. 3. Report the UAP for improper handling of hazardous material. 4. Dispose of the sharps container to prevent any additional injuries to others.

2. Assist the UAP to scrub the wound with copious amounts of soap and water.

The postoperative patient demonstrates some mild dizziness and mild shortness of breath when moving from sitting to standing position. Which action would the nurse perform first? 1. Assist the patient to get into bed. 2. Assist the patient to sit back down. 3. Check vital signs and assess symptoms. 4. Call the provider for an order for oxygen.

2. Assist the patient to sit back down. --> prevents falling

The nurse is sitting at the front desk at a walk-in clinic. A patient comes in and reports fever, malaise, and muscle aches with a rash on the tongue, mouth, and throat. The nurse notes pustules on the patient's palms. What would the nurse do first? 1. Notify the public health department. 2. Isolate the patient. 3. Put on personal protective equipment (PPE). 4. Call the HCP to triage the patient.

2. Isolate the patient.

A patient with a latex allergy is exposed to latex. Which sign or symptom is cause for the greatest concern? 1. Hives 2. Laryngeal edema 3. Runny eyes and nose 4. Localized swelling

2. Laryngeal edema --> airway obstruction

25. Which newly obtained piece of equipment creates the greatest risk for falls for an older adult? 1. Gait belt 2. Prescription lenses 3. Safety bar in shower 4. Walker

2. Prescription lenses

The nurse notices smoke coming from the wastebasket in a patient's room. Upon entering the room, the nurse sees a fire that is starting to flare up. What would the nurse do first? 1. Extinguish the fire. 2. Remove the patient from the room. 3. Close the door to the room. 4. Turn off all electrical equipment.

2. Remove the patient from the room.

The older adult tells the nurse that he is having trouble reading the labels on his medication bottles. What is the best strategy that the nurse could suggest to reduce the risk of an accidental medication error? 1. Recommend that a younger family member assist in handling the pills 2. Teach the patient to use a medication organizer to manage the medication 3. Tell the patient to have the pharmacist read the label information to him 4. Assist the patient to memorize the shape and color of each pull

2. Teach the patient to use a medication organizer to manage the medication

The nurse is preparing to give an intramuscular injection to a patient. What factors would increase the risk of needlestick injury to the nurse? Select all that apply. 1. Using a needle-less device 2. Disposing the needle device in the needle disposal container 3. Applying a Band-Aid to the injection site immediately after administering injection 4. Using a new type of safety device injection system 5. Recapping the needle after the injection 6. Cleansing the skin with an alcohol swab after uncapping the needle

3, 4, 5, 6

The nurse is giving instructions to the UAP about patient safety and fall prevention. What would the nurse tell the UAP about helping the older adult patient to go to the bathroom? 1. "Help the patient whenever she needs help." 2. "Ask her if she wants to walk or use the bedpan." 3. "Have her put on her glasses before getting up." 4. "Help her to the commode chair if she seems weak."

3. "Have her put on her glasses before getting up."

A mother brings her alert and playful child to the clinic because she "found him playing with his emptv bottle of baby aspirin." Which question is the most important to ask the mother? 1. "Has he ever done anything like this before?" 2. "How many times has he vomited since the ingestion?" 3. "How many pills do you think were in the container?" 4. "Did you contact poison control before you drove to the clinic?"

3. "How many pills do you think were in the container?"

For the care of a patient who has an SRD in place, which task can be delegated to a UAP? 1. Observe for circulation distal to the SRD. 2. Check for respiratory effort and breathing. 3. Change position every 2 hours. 4. Determine when the SRD can be removed.

3. Change position every 2 hours.

The nurse is talking to a young mother who has an infant who has just started to crawl. Based on knowledge of growth and develop-ment, which safety issue is currently the most important to discuss with the mother? 1. What to do when using pots and pans on the stove 2. How to ensure backyard pool safety measures 3. How to manage electrical sockets and cords 4. Where to obtain safety labels for cleaning products

3. How to manage electrical sockets and cords

In which clinic setting is the nurse most likely to need knowledge of how to apply safety reminder devices (SRDs) and manage the care of these patients? 1. Pediatric walk-in clinic 2. Outpatient surgery clinic 3. Mental health walk-in clinic 4. Adult ambulatory care clinic

3. Mental health walk-in clinic --> protect against harm from self or towards others

15. The nurse applies a gait belt to a male patient of average build who has some weakness on the left side. How does the nurse position herself before assisting the patient to ambulate? 1. On the patient's left side and holding the weak left arm. 2. On the patient's right side and holding the front of the gait belt. 3. On the patient's left side and holding the back of the gait belt. 4. On the patient's right side and holding one arm around his waist.

3. On the patient's left side and holding the back of the gait belt.

It is suspected that a patient has been exposed to cyanide gas. The nurse is alert for which symptom? 1. Erratic behavior 2. Nausea and vomiting 3. Respiratory distress 4. Vesicle formation

3. Respiratory distress

The nurse started a new job in a small long-term care facility in a rural area. The back exit hallway is being used as a storage area while a new storage area is being planned. What would the nurse do first? 1. Report the facility for unsafe conditions. 2. Express unwillingness to work in unsafe conditions. 3. Review the facility's policies/procedures for emergencies. 4. Check the building for other safety issues.

3. Review the facility's policies/procedures for emergencies.

The patient with mild cognitive impairment is being discharged from the hospital with several new medications. Which action by the nurse would be most effective in reducing the risk of accidental poisoning by medication misuse? 1. Teach the patient the names, doses, potential side effects, and indication for use for each medication. 2. Request that the patient have their adult son come to safely set up the medications each day. 3. Teach the patient how to use a medication box and reminders. 4. Teach the patient how to organize the medications on the day of discharge.

3. Teach the patient how to use a medication box and reminders.

Which instructions would be given to the UAP who is assigned to assist in the care of a patient who is being treated with internal radiation? 1. "Do not go into the room unless the patient uses the call bell." 2. "Help children to don a lead shield apron before entering the room." 3. "Wear a mask, eye shield, and isolation gown when entering the room." 4. "Wear your personal dosimeter during care or when handling patient items."

4. "Wear your personal dosimeter during care or when handling patient items." --> anyone involved in the care of a patient who is receiving internal radiation should wear their own dosimeter

A confused patient is yelling at the UAP. As the nurse enters the room, the patient throws the food tray at the UAP. What would the nurse do first? 1. Ask the UAP to explain what is happening with the patient. 2. Instruct the UAP to move toward the door and then slowly shut it 3. Slowly walk toward the patient and use a gently touch to soothe it. 4. Calmly talk to the patient and respectfully address him by his name

4. Calmly talk to the patient and respectfully address him by his name

The nurse is caring for patients who relies on mechanical ventilation. The nurse hears a fire alarm and flames are visible in a back corridor. What would the nurse do first? 1. Seek assistance to move the patient and ventilator to safety 2. Turn off the oxygen supply and provide manual respiratory support 3. Close the patient's door, call 911, and fight the fire in the corridor 4. Delegate the UAP to move ambulatory patients toward the exit

4. Delegate the UAP to move ambulatory patients toward the exit --> initiating phase one of rescue

An infant has a wound with a dressing on the left upper arm. He repeatedly attempts to remove the dressing. Which SRD would the nurse select? 1. Mummy wrap 2. Wrap jacket 3. Bilateral wrist SRDs 4. Right elbow SRD

4. Right elbow SRD