Fundamentals of Nursing CH 19: Safety

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention?

Apply an allergy-alert identification bracelet on the client.

The nurse is assessing a client's mental health competence and decision-making ability. Which activity will best provide the needed information to the nurse?

Ask the client "what if" questions to determine level of thought organization

The nurse is teaching the caregiver of a school-age child about safety. Which teaching will the nurse include?

Buy protective sporting equipment.

A nurse is educating the family caregiver of an older adult client about measures to promote client safety in the home. What would be most appropriate to include?

"Clear the clutter from the stairways and walkways."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

"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?"

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?

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

A nurse is caring for an 18 month-old boy status post a tracheostomy. He is recovering well and wanting to be more active. The nurse selects a toy from the playroom for him to play with. Which toy is most developmentally appropriate?

A rocking horse

A parent visits the pediatrician's office and complains to the nurse practitioner about her teenager who sleeps too much. It would be appropriate to instruct this parent that

Adolescents need more sleep for growth

The client tells the nurse that he needs to use the restroom. Which safety intervention must be done by the nurse first?

Assess the need for assistance with ambulation.

What national organization determined that unintentional injuries were the fifth-leading cause of all deaths in the United States?

Centers for Disease Control and Prevention

A nurse hears a client call and finds that the client's room has caught fire due to an electrical short circuit. The nurse evacuates the room and raises an alarm. Which of the following types of extinguishers should the nurse use in this situation?

Class C

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

Client-centered care Teamwork and collaboration Quality improvement (QI)

Which item would alert the home care nurse to a safety hazard threatening a young child?

Dangling blind cords

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.

Falls from stairs Accidental drowning Electrocution from outlets

An older adult woman in a long-term care facility has fallen and sustained several injuries. Which of her injuries would be the most serious fall-related injury?

Fractured hip

A nurse finds a client in his room asphyxiated with carbon monoxide (CO) inhalation. Which activity should be the priority for the nurse?

Get the victim out of the present environment.

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?

Hair dryer is placed next to the sink.

The older adult will have an increased risk for developing which of the following?

Heatstroke

A nurse makes a medication error and reports it to the nurse manager, requesting assistance filling out the incident report. What should the nurse manager educate the nurse about regarding the incident report? Select all that apply.

It should provide a clear, concise recording of the situation It should include factual information about the incident.

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?

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

Which level of health care provider may make the decision to apply physical restraints to a client?

Nurse practitioner

The nurse is caring for a client with confusion who has been placed into soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action is appropriate? (Select all that apply.)

Obtain order from a licensed provider within 1 hour of restraint application. Offer regular, frequent opportunities for toileting.

A nurse is assigned to care for a 10 month-old boy. Which activity should be the priority for the nurse?

Protect the toddler from injury.

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

The nurse has received a medication order over the telephone from a provider. What is the next appropriate nursing action?

Repeat or read back the order.

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?

Rescue anyone who is in immediate danger.

An elderly client has a diagnosis of vascular dementia and has been found wandering the hospital unit at numerous times during the day and night. The nurse should assign what priority nursing diagnosis to this client's behavior?

Risk for Falls

What generalization can be made about safety in client care?

Safety is a paramount concern underlying all nursing care.

A group of nursing students is reviewing information about restraints. The students demonstrate understanding of the information when they identify which of the following as a chemical restraint

Sedative

A group of nursing students is reviewing information about restraints. The students demonstrate understanding of the information when they identify which of the following as a chemical restraint?

Sedative

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

Social pressure

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 leaning against the screen of a window in a classroom.

The nurse needs to plan the interventions necessary to reduce fall risks for the older adult clients at her facility. Which is the strongest indicator that a client is at risk for falls?

The client has fallen before.

When administering an injection to a client with hepatitis C in a health care facility, the nurse sustained a needlestick injury. Which ensuing action would be most important?

The nurse needs to file an incident report after the event occurs.

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 question the client about the source of the bruises.

In large metropolitan areas, clients who suffer from asthma will be affected by:

air pollution

A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to:

experimentation with drugs and inhalants.

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:

falls

What is the leading cause of injury-related deaths in adults 65 and older?

falls

The surgical nurse is preparing a client for surgery on the left leg. The client is awake, alert, and oriented. Who does the nurse identify that should mark the leg that will undergo the surgical procedure? (Select all that apply.)

nurse surgeon client

The nurse is caring for a client with dementia who lives alone at home and has begun wandering. What is the appropriate nursing response when the caregiver states, "What can I do? I am afraid my spouse is going to get lost."

"Consider the Alzheimer's Association 'Safe Return' program."

The nurse is caring for a client with a latex allergy. When ordering lunch for the client, which food does the nurse cross off of the menu that should not be consumed?

1 medium Banana

A nurse is administering a scheduled medication to a client using the institution's bar code system. The nurse has scanned the client's armband as well as the scheduled medication. The system has signaled a discrepancy between the dose ordered and the dose scanned. What is the nurse's most appropriate response?

Consult with a colleague and identify the source of the error signal before proceeding.

When educating parents of preschoolers, what is most important for the nurse to include in the presentation?

Keep chemicals in a locked cabinet.

A nurse is caring for a restrained client who has suicidal tendencies. Which of nursing diagnosis is most appropriate for this client?

Risk for Injury

Which nursing diagnosis would be appropriate for educational interventions for a single mother who leaves her toddler unattended in the bathtub?

Risk for Suffocation

A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury?

"Always test the temperature of bath water before stepping in."

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?

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

Which topics should be included in an education plan for preventing falls in the home? Select all that apply.

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

Which intervention to prevent client falls in the acute care setting requires collaboration with a client's primary care provider?

Avoid the use of medications that increase the likelihood of falls.

The facility where the nurse works has changed from latex gloves to vinyl, powder-free gloves to protect clients with latex allergies. Which education will the nurse provide to the unlicensed assistive personnel (UAP) about this new type of glove?

Gloves must be changed every 30 minutes to maintain barrier protection.

One of the leading causes of death in the United States, particularly in southwestern states, is drowning. How can the nurse assist in lowering this statistic?

Implement drowning-prevention strategies.

A nurse is caring for a confused client in a long-term care facility. The client is not allowed to get out of bed. The nurse requests restraints for the client. Which guidelines for the use of restraints should the nurse follow? Select all that apply.

Involve the client's family in the decision and plan of care. Alternatives to restraints and less restrictive interventions must have been implemented and failed. The benefit gained from using a restraint must outweigh the known risks for that client.

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?

Open garage door and windows, and call 9-1-1.

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident?

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

A male client with early-stage Alzheimer disease is being discharged home after a hospital admission and his wife will be his sole caregiver. What action should the nurse encourage the wife to take in order to reduce her husband's risk of experiencing a fall in the home?

Teach the wife to remove loose rugs from the floors in the home.

Root cause analysis is being performed after a client who was supposed to be on falls precautions fell while trying to walk to the toilet. Which finding of the investigation would be considered to be a latent error?

The documentation forms on the unit have no specified location where falls precautions should be noted.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure ulcer on his 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?

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

A nurse was injured when a client with Alzheimer's disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

The report provides a detailed and objective account of the circumstances before, during, and after the event.

The nurse is caring for a client who has been repetitively pulled at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the healthcare provider orders chemical restraints. Which treatment does the nurse anticipate?

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

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client?

an 84-year-old male with four recent driving violations

A nurse visits an elderly client at home and assesses the safety of the client's environment. Which article can be a threat to the client's safety? (Select all that apply.)

area rugs kept on the stairs without carpet dimly lit hallways waxed floors

After performing neuro checks every 2 hours after an ischemic stroke, the nurse determines the client's neurological status is deterioriating. Which nursing action best prevents an adverse outcome in this client's care?

assessing the client's neurological status more frequently than ordered

The nurse has delegated several parts of basic care for a client who is a fall risk to an unlicensed assistive personnel (UAP) member. Which UAP action requires nursing intervention?

assisting the client to put on slippers prior to ambulation

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out an electrical fire, what will the nurse identify?

class C

During discharge planning, the nurse is assessing home safety for a client who has repeatedly fallen. Which condition increases the client's risk for falls? Select all that apply.

climbs two flights of stairway to get to his bedroom prefers to use the bathtub when taking a bath drinks 2 shots of alcoholic beverages before dinner takes a diuretic pill early in the morning

A nurse has been appointed to oversee safety measures in an assisted living facility that caters to older adults. The nurse should prioritize measures aimed at reducing residents' risks of:

falls.

A client went missing from a long-term care facility and an emergency code was called. After a search of one hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

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

A nurse on a medical unit recognizes the need to demonstrate Quality and Safety Education for Nurses (QSEN) competencies in clinical practice. Which action best demonstrates the skills necessary to meet the QSEN competency of safety?

filling out an incident report accurately after a client went missing from the unit

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

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers

A nurse is providing care for a client whose blood pressure has been gradually dropping over the course of a shift. The nurse has decided to inform the client's primary care provider by telephone using the SBAR tool. The nurse will end this communication by:

making a suggestion about what she believes to be the best actio

Which agent has the potential to affect the integrity of latex gloves?

oil-based lotions

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:

polypharmacy and use of multiple extension cords.

The occupational health nurse is planning a safety in-service for a group of clerical workers. Which topic would be most beneficial?

principles of body alignment

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?

provides slippers for ambulation

Over the past few weeks, 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 does not comply with a least restraint policy?

raising all side rails while the client is in bed

The nurse is caring for a client who has been repetitively pulled 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?

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

A client has been discharged from the hospital after being treated for a myocardial infarction. The client has been asked to evaluate the care received by completing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The results of this survey may affect:

the amount of money the hospital receives from the Centers for Medicare & Medicaid Services.

A nurse instructs a group of parents of preschool-age children that the rules of safe social interaction for this age group are often learned by:

trial and error.

There is a fire in the neurology unit of a health care facility. What would be most appropriate to avoid in this situation?

use of elevators

A group of girls is camping in the woods with camp counselors. They should be instructed to:

use the buddy system

A nurse is working as an industrial nurse. Which activity would the nurse suggest that the employers adopt to prevent carbon monoxide (CO) inhalation by the workers?

using carbon monoxide detectors and alarms

A nurse is preparing a community lecture about safety considerations for various age groups. For which age group would the nurse especially emphasize the prevention of falls?

older adults

The nurse is teaching a nursing student about proper latex glove use. Which nursing student action requires intervention by the nurse? (Select all that apply.

"snapping" the gloves when applying them to ensure proper fit wearing gloves for long periods of time after procedure ends

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?

1 hour

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug abuse?

19-year-old male college student majoring in physics

A nurse is administering the Hendrich Fall Risk Tool to a client. What is the cutoff Final Risk Score for the client to not be considered at risk for falling? Record your answer using a whole number.

5

The facility is conducting an educational seminar for newly employed nurses. The program addresses the reporting of sentinel events. Which occurrences qualify for this criteria? Select all that apply.

A client's baby is misidentified and receives breast milk from another mother. A client faints during ambulation with the nurse, resulting in a concussion. The nurse administers a lethal dosage of medication in error.

Which action directly addresses one of the Joint Commission 2015 Hospital National Safety Goals?

A hospital has set ambitious targets for reducing the incidence of catheter-related urinary tract infections.

A nurse is providing a safety program on childhood poisoning for a group of parents of young and school-age children. The nurse determines that the education was successful when the group states:

Berries and seeds that children find out in the woods are not safe to for them to eat."

The nurse is teaching the parents of a teenager about safety. Which teaching will the nurse include?

Be alert for signs of peer pressure

The nurse is teaching the parents of a teenager about safety. Which teaching will the nurse include?

Be alert for signs of peer pressure.

The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which topic for staff education is most likely to benefit the greatest number of residents?

Educating nurses on how to prevent falls

A 79-year-old client with a history of osteoporosis experienced a fall while attempting to walk independently to the hospital washroom to urinate. How can the nurse best prevent a repeat of this incident?

Encourage the client to ring the call bell when the client has the urge to void.

The nurse is caring for a client who has an indwelling urinary catheter. A care bundle is being used to guide the client's catheter care. What are likely elements of the care bundle? Select all that apply.

Ensure that the client's meatus is cleansed at least once per day. Evaluate the client's need for the catheter on a daily basis. Apply standard precautions when providing catheter care.

A nurse finds that a fire has broken out in a client's room at the health care facility. Place the steps the nurse should take in the correct sequence, from first to last.

Evacuate the client. Raise an alarm. Confine the fire. Extinguish the fire.

The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes?

Suggest to the nurse manager that an in-service on abbreviation use would be helpful.

The nurse is teaching the caregiver of a 1-year old about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

The nurse is teaching the caregiver of an infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

The goal of evidence-based practice related to restraints is to avoid the use of restraints.

True

A 14-year-old boy is in the clinic for his well-child exam. When the client asks his mother if she has any questions for the practitioner, she states "He sleeps so much. I am worried about how lazy he is." What does the nurse know to be true about sleep in adolescents?

Trying to balance too many activities can result in sleep deprivation.

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group?

Use protective sporting equipment

The nurse is teaching a nursing student about proper latex glove use. Which teaching will the nurse include?

Wash hands thoroughly after removing gloves with a pH balanced soap.

A child is learning to ride a bicycle. He should be instructed to use which of the following protective devices?

Helmet

What teaching will the community health nurse include for parents of toddlers?

Household cleaners must be kept out of reach.

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective

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

A large health care organization has committed to promoting a just culture when adverse events and near misses take place. Which question will guide the organization's response when a nurse commits an error?

"How did the nurse's actions contribute to this error?"

Which statement by a client would indicate that a nurse had successfully implemented an educating/learning strategy to prevent injury in the home?

"I am going to remove all those throw rugs on the floor."

The nurse is caring for four clients. Which client does the nurse anticipate is at highest risk for latex sensitivity?

27-year old who cannot eat avocados

An 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?

Activate the fire alarm and notify the appropriate person.

The nurse is reviewing a healthcare provider's orders in the electronic health record (EHR) and notices several abbreviations. What is the appropriate nursing action?

Contact healthcare provider to clarify order.

A caregiver of a toddler has called the poison control nurse to report that the child licked a small amount of petroleum jelly. The caregiver states that the toddler is sitting on the floor, watching a cartoon, and playing with a toy. Which information will the poison control nurse provide?

Dilute with water or milk.

A nurse is providing instructions to the mother of a toddler regarding the prevention of burn injuries in the toddler. Which instruction is the priority to provide to the mother?

Keep coffee cups on the counter above the child's reach.

A fire has erupted in the trash can on the unit and the nurse implements the protocol for fire safety for the facility. Another nurse obtains the fire extinguisher and is preparing to use it. What would the nurse do first?

Pull the pin.

A team of inner city school nurses attends a community conference on child safety during the summer months. What would be the priority health outcome that these nurses would expect to achieve in summer school?

The students will demonstrate proper use of safety equipment while playing sports.

When educating families on fire safety, it is important to:

have a meeting place outside the home.

The nurses on a critical care unit can utilize the safety strategy of redundancy by:

having two nurses independently check the dosage of high-risk medications.

An 18-year-old boy is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

sports-related activities.

The nurse is caring for a client with a latex allergy. When the dietary tray arrives, the nurse notes that it contains a hamburger with lettuce and tomato, baked potato, apple, chocolate chip cookie, and small serving of milk. What is the appropriate nursing action?

Call Nutrition Services for a plain hamburger.

A nurse is caring for an a client with asthma who has developed severe allergic reactions to latex. Which measure should the nurse take to protect a latex-sensitized client?

Keep the client's unit free from latex products

An older adult client is planning to move with her son and daughter-in-law into a bigger apartment. The son asks the nurse for some tips to keep his mother safe. What would the nurse most likely include?

Put a small nightlight in the hall and stair.

The acronym health care workers use to remember the safety procedures in the event of fire is:

RACE (rescue; alarm; confine; evacuate).

The nurse is admitting a client to a medical-surgical unit who states, "If someone brings balloons to me, I might have trouble breathing." What is the appropriate nursing action?

Replace common healthcare items with latex-free equipment.

A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of medication. Which measure would be most effective at protecting a toddler from accidental poisoning with medication?

Request childproof caps on all prescription medications.

The nurse is assessing the client's sensory input. Which assessments should be included? Select all that apply

Sensitivity to touch Sensitivity of sharp to dull stimulation Ability to maintain balance

The nurse is preparing to administer medication to a client. Which validation of client information is appropriate?

full name and date of birth

The residential home nurse is caring for a client who lives in an assisted living unit. In designing a plan of care to prevent fires, the nurse identifies which as the highest risk to the client?

gas stove

The nurse is conducting a home care visit for a new mother who delivered a baby 3 days ago. Which finding within the home requires immediate nursing intervention?

hot water heater thermostat set at 130 degrees F (54.4 degrees C)