Fundamentals Quiz #1 (safety)

A nurse identifies the presence of smoke exiting the door to a the dirty utility room. place the nurses actions in order of priority using the RACE model.

1. pull the fire alarm 2. shut the door to the utility room 3. close unit doors and windows 4. provide emotional support to agitated clients

Which is an appropriately worded goal for a client who is at risk for falling?Select all that apply

--"the client will be able to walk from a bed to a chair safely while hospitalized" --"the client will be free from trauma"

Which intervention should a nurse implement when assisting a client to use a bed pan?

--ensure that the bed rails are raised after the client is on the bed pan --position the rounded rim of the bed pan under the clients buttocks --encourage the client to help as much as possible when using the bedpan --raise the head of the bed to the semi-fowler position once the client is placed on the bedpan

Which human response to illness alerts the nurse that a client is at risk for aspiration during meals? Select all that apply

-lethargy -stomatitis -dysphagia

A nurse uses the "get up and go" test to assess a client for weakness, poor balance, and decreased flexibility. Place the following actions in the order in which they should be implemented when employing the "get up and go" test.

1) ask the client to sit in a chair 2) ask the client to stand 3) ask the client to close the eyes 4) ask the client to open the eyes 5) ask the client to walk 10feet and then to return to the chair

A toaster is on fire in the pantry of a hospital unit. Which should the nurse do first?

Activate the fire alarm

The risk management coordinated is preparing a program on the factors that contribute to falls in a hospital setting. Which factor that most often contributed to falls should be included in this program?

Advanced age of clients

A nurse is caring for a client with Parkinson's disease who is experiencing difficulty swallowing. For which major potential problem associated with dysphasia should the nurse asses the client?

Aspiration

Which should the nurse do to best prevent a client from falling?

Assist the client with ambulation

A nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized client should they be taught is at the highest risk for injury?

Confused middle age man

A client brings several electronic devices to a nursing home. One of the devices has a two pronged plug. Which rationale should the nurse provide when explaining why an electrical device must have a three pronged plug?

Controls strat electrical currents

A nurse is implementing the action demonstrated in the illustration (hiemlich manuever) Which is the nurse doing?

Dislodging an object from a clients airway

A male client is admitted to ambulatory care for a bilateral herniorrhaphy. A nurse on the unit interviews the client, obtains the clients vital signs, and reviews the primary healthcare providers prescriptions. Which should the nurse do first?

Ensure the clients allergy band includes the clients identified allergens

A nurse in the nursing education department of a community hospital is planning an in service education class about injury prevention. Which factor that most commonly caused physical injuries in hospitalized clients should be included in the teaching plan?

Falls

A nurse must apply a hospital gown that does not have snaps on the shoulders to a client receiving an IV infusion to the forearm. Which should the nurse do?

Insert the clients IV bag and tubing through the sleeve from inside of the gown first

Which is the last step in making an occupied bed that the nurse should teach a nursing assistant?

Lowering the height of the bed toward the floor

A nurse is caring for a confused client. Which should the nurse do to prevent this client from falling?

Maintain close supervision

A nurse is caring for a client with dementia. What time of day is of most concern for the nurse when trying the protect this client from injury?

Night

A primary healthcare provider prescribed a vest restraint for a client. Which should the nurse do first when applying this restraint?

Perform an inspection of the clients skin where the restraint is to be placed.

A nurse is caring for a client with a nasogastric tube for gastric decompression. Which nursing action takes priority?

Positioning the client in the semi-Fowler position

Which action is important when the nurse uses a stretcher? Select all that apply

Pushing the stretcher from the end with the clients head

A nurse is caring for a client with a moderate problem with balance. Place an X over the cabe that is most appropriate for this client.

Quad cane

A school nurse is teaching children about fire safety procedures. Which is the first thing they should be taught to do if their clothes catch on fire?

Roll on the ground

An unconscious client begins vomiting. In which position should the nurse place the client?

Side-lying

A family member brings an electric radio to a client in long term care facility. The client tells the nurse that an electric shock was felt when turning on the radio. Which should the nurse do first?

Take the clients apical pulse

A nurse is assessing a client who is being admitted to the hospital. Which is the most important info that indicates whether the client is at risk for physical injury?

Two recent falls that occurred at home

A client has dysphagia. Which nursing actions takes priority when feeding this client?

checking the mouth for emptying between every bite

A home care nurse is assigned to care for an older adult living at home. Which is the first action the home care nurse should employ to prevent falls by this older adult?

conduct a comprehensive risk assessment

a 3 year old child is admitted to the pediatric unit. Which should the nurse do to maintain the safety of this preschool aged student?

ensure the child is under continuous supervision

A nurse is preparing a bed to receive a newly admitted client to the hospital. Which action is most important?

ensuring that the bed wheels are locked

A nurse is planning care for a client with a wrist restraint. How often should a restraint be removed, the area massaged and the joint moved through their full range?

every 2 hours

Which is the priority nursing intervention to prevent client problems associated with latex allergies?

identify persons at risk

a nurse is preparing a client for a physical examination which is the most important for the nurse to do in this situation?

identify the positions contraindicated for the client during the examination

Profuse smoke is coming out of the heating unit in a patient's room. What should the nurse do first?

move the client out of the room

a nurse is orienting a newly admitted client to the hospital. Which is the most important for the nurse to teach the client how to do?

notify the nurse when help is needed

which nursing intervention enhances an older adults sensory perception and thereby helps prevent injury when walking from the bed to the bathroom?

providing adequate lighting

which clinical

—debris in the buccal cavity -coughing episodes -noisy breathing -slurred speech -drooling

An adult client consistently tries to pull out a nasogastric tube. As a last resort to maintain integrity of the tube and client safety, the nurse obtains a prescription for a restraint. Which type of restraint is appropriate in this situation? Select all that apply

—elbow restraint -wrist restraint -mitt restraint

A nurse is planning care for a client who requires bilateral arm restraints because the client is delirious and attempting to pull out a urinary retention catheter. Which info is important to consider when planning care for this client? Select all that apply

—reasons for use of restraints must be clearly documented —laws permit the use of restraints when specific guidelines are followed