Learning Unit 4 | PrepU | Chapter 19: Safety

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? 20 5 15 10

5

Which client will the nurse assess for sensory-perceptual alterations? 12-year-old client who sprained their wrist skateboarding 42-year-old client who is a single parent with a sick child home from school 84-year-old client with four recent driving violations 16-year-old pregnant client who has morning sickness

84-year-old client with four recent driving violations

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. No extension cords are being used. Machines used infrequently are unplugged.

A hair dryer is placed next to the sink.

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention? Flag the room door. Teach the client to wear a Medic-Alert bracelet. Apply an allergy-alert identification bracelet on the client. Notify the interdisciplinary health care team to use nonlatex equipment.

Apply an allergy-alert identification bracelet on the client.

A nurse is caring for a restrained client who has suicidal tendencies. How should the nurse intervene to decrease the risk of injury? Remove restraints two at a time, every 2 hours Assess for circulation, movement and sensation Ensure client can move enough to maintain personal hygiene Confirm that the restraint is as tight as possible

Assess for circulation, movement and sensation

When educating parents about the safety of preschool-aged children, which is most important for the nurse to include in the presentation? Weapons should be kept in a closet to prevent access by children. Safety equipment should be used during sports activities to decrease fear. At home chemicals should be kept in a locked cabinet. Teach children to greet unfamiliar animals to make friends.

At home chemicals should be kept in a locked cabinet.

Which intervention to prevent client falls in the acute care setting requires collaboration with a client's primary care provider? Educate the client about the proper use of the call bell system. Activate the pressure sensor alarm on the bed (if equipped). Avoid the use of medications that increase the likelihood of falls. Institute a toileting schedule if appropriate.

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

A client with diabetes has impaired sensation in the lower extremities. What education would be necessary to reduce the client's risk of injury? "Take your insulin twice a day as we have discussed." "Rub lotion on the skin of your legs and feet twice a day." "Remember to follow your diet so you lose weight this month." "Always test the temperature of bathwater before stepping in."

"Always test the temperature of bathwater before stepping in."

A nurse is providing a safety program on childhood poisoning for a group of parents of preschool and school-age children. The nurse determines that the education was successful when the makes which statement? "Household chemicals should be stored in plastic bags after removal from the original container." "Tulips and daffodils are safe houseplants, and they make the environment pleasing." "Berries and seeds that children find out in the woods are not safe for them to eat." "Ipecac syrup should be given to induce vomiting in suspected ingestion of poisons."

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

Which statement by a client would indicate that a nurse had successfully implemented an educational strategy to prevent injury in the home? "I place my phone next to my bed during the night for emergencies." "I have removed all throw rugs on the floor." "I turn off the outside lights and lock the doors every night." "I have taken a CPR and first aid class."

"I have removed all throw rugs on the floor."

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 client 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 clients."

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

"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." "Concussions happen often in children of this age group, and they always bounce back fine." "Wearing bicycle helmets will keep your child safe from head injuries." "Try to keep him resting for a few days at home using the television and his video games."

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

The nurse is presenting content on fire safety to a family. One of the family members tells the nurse that they have designated a meeting spot in their front yard in case of fire and that they practice using escape routes. Which is the nurse's best response? "It's preferable to have a meeting place that's at least 100 yards from your home." "Make sure your escape route passes through each family member's bedroom." "That's an important part of an overall fire safety plan." "It's preferable to focus on fire extinguisher safety because most people can't follow escape routes in a fire."

"That's an important part of an overall fire safety plan."

The nursing supervisor is concerned about excessive use of physical restraints on the unit. What interventions would the nursing supervisor employ to decrease the use of restraints? Select all that apply. Evaluate each client who is restrained and consult with the client's nurse about the use of the restraint. Obtain additional bed alarms or position-sensitive electronic devices for use as needed. Provide classes for the nursing staff about appropriate use of restraints and alternatives to restraints. Review and change, if needed, current policies at the agency for adherence to accepted national standards. Encourage the nurses to use medications instead of physical restraints.

- Review and change, if needed, current policies at the agency for adherence to accepted national standards. - Provide classes for the nursing staff about appropriate use of restraints and alternatives to restraints. - Evaluate each client who is restrained and consult with the client's nurse about the use of the restraint. - Obtain additional bed alarms or position-sensitive electronic devices for use as needed.

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

19-year-old male college student majoring in physics

A fire has erupted in a trash can on the unit. The nurse obtains the fire extinguisher and is preparing to use it. Arrange the sequence of steps that the nurse should follow. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Squeeze the handle. 2Aim the nozzle. 3Pull the pin. 4Sweep back and forth.

3 2 1 4

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. Withhold information from family regarding restraints due to HIPAA. Maintain restraints until discharge. Check circulation and skin condition every 2 hours. Offer regular, frequent opportunities for toileting. Obtain order from a licensed provider within minutes of restraint application.

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

A nurse is providing an in-service program for staff on fire safety and is reviewing the types of fire extinguishers available. Which class of fire extinguisher would the nurse describe as appropriate for use on an electrical fire? Class A Class D Class B Class C

Class C

The nurse is reviewing a health care provider's orders in the electronic health record (EHR) and notices several abbreviations. What is the appropriate nursing action? Administer medications as ordered. Contact the health care provider to clarify the orders. Fix the abbreviations in the EHR. Confirm the abbreviations with another nurse.

Contact the health care provider to clarify the orders.

The nurse is reviewing a health care provider's orders in the electronic health record (EHR) and notices several abbreviations. What is the appropriate nursing action? Contact the health care provider to clarify the orders. Fix the abbreviations in the EHR. Confirm the abbreviations with another nurse. Administer medications as ordered

Contact the health care provider to clarify the orders.

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? Induce vomiting. Call 911. Dilute with water or milk. Administer a laxative.

Dilute with water or milk.

The school nurse is evaluating a school's response to a fire drill. Which action requires the school nurse to provide teaching to the schoolteachers, staff, and students? Select all that apply. Children in wheelchairs have teachers assist them during evacuation. Doors of classrooms and offices are open. Elevators are used to increase the speed of vacating the building. Hallways are cleared of visitors. Windows to the building are closed.

Doors of classrooms and offices are open. Elevators are used to increase the speed of vacating the building.

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. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 4Raise an alarm. 2Confine the fire. 3Extinguish the fire. 1Evacuate the client.

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

There is a fire in the trashcan in the client's room. What is the nurse's first priority? Pull the alarm and alert appropriate personnel. Remove the client from the room. Close all doors and windows. Extinguish fire.

Extinguish fire.

A client has presented to the emergency department after splashing a caustic chemical in the eyes. When managing the injury, what should be included in the plan of care? Flush the eyes with a cool saline solution for a 10-minute period. Advise the client to avoid blinking until after the eyes are irrigated. Flush the eyes with water for 10 minutes. Wash the eyes with a hypertonic solution for at least 30 minutes.

Flush the eyes with water for 10 minutes.

A nurse finds a client in his room asphyxiated with carbon monoxide (CO) inhalation. Which activity should be the priority for the nurse? Treat the client with hyperbaric oxygen. Get the victim out of the present environment. Provide oxygen administration and resuscitation. Go to the nursing unit and call for help.

Get the victim out of the present environment.

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. Implement drowning prevention strategies. Begin swim lessons with toddlers. Educate children in cardiopulmonary resuscitation.

Implement drowning prevention strategies.

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

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

A nurse is caring for a client with asthma who has developed severe allergic reactions to latex. Which measure should the nurse take to protect a latex-sensitized client? Instruct the client not to touch latex products in their room. Use only sterile latex gloves for the client during procedures. Keep the client's unit free from latex products. The nurse should wash their hands thoroughly before donning gloves.

Keep the client's unit free from latex products.

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

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

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? Instruct the caller to quickly administer oral fluids. Turn the car's air conditioner on to circulate flow of air. Open garage doors and windows, and call 911. Direct the caller to search for a carbon monoxide detector in the garage.

Open garage doors and windows, and call 911.

The nurse is caring for an older adult client who has a cognitive impairment and frequently wanders. The nurse will implement which action(s) into the client's plan of care? Select all that apply. Apply physical restraints at regular periods throughout the day. Have facility security personnel assist when the client is agitated. Encourage the client to walk outdoors when weather permits. Place a bell over the client's room and other facility doors. Check that all exit doorways have a STOP sign posted.

Place a bell over the client's room and other facility doors. Check that all exit doorways have a STOP sign posted.

A nurse is assigned to care for a 10-month-old boy. Which activity should be the priority for the nurse? Provide sensory stimulation. Protect the toddler from injury. Provide health education to parents. Spend time with the toddler in the play room.

Protect the toddler from injury.

An older adult client is planning to move with the son and daughter-in-law into a bigger apartment. The son asks the nurse for some tips to keep the parent safe. Which safety principles should the nurse include in the client teaching? Decorate the parent's room with small rugs and wall hangings. Put a small nightlight in the hall and stairway. Combine medications into a few pill bottles for ease of use. Locate the parent in a room near the kitchen.

Put a small nightlight in the hall and stairway.

The nurse is caring for a client that is agitated and combative. What action can the nurse take other than the use of physical restraints? Select all that apply. Provide a safe environment. Use simple, clear explanations and directions. Distract and redirect in a commanding voice. Place all four side rails up. Reduce stimulation, noise, and light. Use a large plant or piece of furniture as a barrier to limit wandering from the designated area.

Reduce stimulation, noise, and light. Provide a safe environment. Use simple, clear explanations and directions. Use a large plant or piece of furniture as a barrier to limit wandering from the

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

Refrain from using extension cords.

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply. Remove extension cords from open spaces. Store prescription medications on the counter. Remove throw rugs from high traffic areas. Ensure appropriate lighting in hallways and entrances to the home. Check the batteries in all smoke detectors.

Remove extension cords from open spaces. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas. Check the batteries in all smoke detectors.

The nurse has received a medication order over the telephone from a provider. What is the next appropriate nursing action? Document the order in the electronic health record (EHR). Identify the client by last name and date of birth. Repeat or read back the order. Prepare the medication for administration.

Repeat or read back the order.

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? Assure the client that balloons do not cause breathing difficulties. Replace common health care items with latex-free equipment. Keep balloons on the opposite side of the client's room. Remind the client that oranges and spinach can cause a cross-reaction.

Replace common health care items with latex-free equipment.

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 health care items with latex-free equipment. Assure the client that balloons do not cause breathing difficulties. Keep balloons on the opposite side of the client's room. Remind the client that oranges and spinach can cause a cross-reaction.

Replace common health care items with latex-free equipment.

Which measure would be most effective at protecting a toddler from accidental poisoning due to the ingestion of medication? Closely monitor the toddler's activity throughout the day. Store all medications in a designated kitchen cabinet. Make sure medications are clearly labeled as such. Request childproof caps on all prescription medications.

Request childproof caps on all prescription medications.

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. Attempt to extinguish the fire.

Rescue anyone who is in immediate danger.

An older adult 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? Insomnia Risk for Falls Impaired Physical Mobility Risk for Impaired Skin Integrity

Risk for Falls

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? Correct the abbreviations in the EHR. Contact the facility's information technology department to delete abbreviations. Suggest to the nurse manager that an in-service on abbreviation use would be helpful. Ask another nurse to fix the abbreviations.

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

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. Keep medications out of reach. Supervise your child on the changing table. Buy protective sporting equipment.

Supervise your child on the changing table.

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

Supervise your child on the changing table.

A male client with early-stage Alzheimer's 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. Encourage the wife to obtain a wheelchair for the husband to use in the home. Encourage the wife to keep her husband in bed whenever possible. Teach the wife to ensure that the husband does not wear shoes while in the house.

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

The nurse has just admitted a client preoperatively to a surgical unit. The client will undergo a surgical procedure the following day. After reviewing the chart, the nurse will prioritize communication to the care team regarding what client data? The client has voiced a strong preference to be admitted to a single room. The client identifies as a "strict vegetarian." The client has a history of anxiety related to previous hospitalizations. The client has had an anaphylactic response to latex products.

The client has had an anaphylactic response to latex products.

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? Increased sleep is the result of boredom. Trying to balance too many activities can result in sleep deprivation. Adolescents require less sleep than adults; this is clearly an underlying medical concern. Increased sleep guarantees adolescents will behave in a safe manner.

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

The nurse is teaching a nursing student about proper latex glove use. Which teaching will the nurse include? Snap the gloves when applying them to ensure proper fit. Wash hands thoroughly after removing gloves with a pH-balanced soap. Use hand cream or lotion after removing gloves to preserve skin integrity. Use powdered gloves.

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

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

a dose of an antipsychotic

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

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

A nurse is making a visit to a client's home and, during the assessment, the nurse notices some possible hazards. What would the nurse identify as potential hazards? Select all that apply. clutter on the stairs evidence of mice droppings electrical outlet with several extension cords wall-to-wall carpeting hair dryer stored in hall cabinet nonworking smoke detector

clutter on the stairs evidence of mice droppings electrical outlet with several extension cords nonworking smoke detector

The nurse is caring for several clients on medical unit. When planning client care, the nurse anticipates which client will be the most likely candidate for the use of a waist restraint? confused client who persistently tries to get out of bed following hip surgery 16-year-old client who is agitated due to illicit substance use client who is confused and may dislodge an in-situ foley catheter client with dementia who has a history of wandering

confused client who persistently tries to get out of bed following hip surgery

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 educating nurses on how to prevent wandering by confused residents reviewing resuscitation for cardiac and respiratory arrest reviewing safe medication administration

educating nurses on how to prevent falls

The school nurse is providing education on poisoning risks to adolescent students. Which topic does the nurse include in the teaching? ingestion of laundry cleaning agents experimentation with drugs and inhalants ingestion of substances in the home that contain lead poisoning from polypharmacy

experimentation with drugs and inhalants

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? electrical sockets clothes dryer cigarette smoking gas stove

gas stove

The nurse obtained the above assessment data for a newly admitted client. The nurse prioritized that this client has a risk for falls. What information in the client data places the client at risk? Select all that apply. age of 61 years history of a fall fractured leg administration of oxycodone vital signs

history of a fall fractured leg administration of oxycodone

The nurse is conducting a home care visit for a new mother who delivered an infant 3 days ago. Which finding within the home requires immediate nursing intervention? one fire extinguisher noted in the kitchen infant's sleepwear is made from flame-resistant fabrics hot water heater thermostat set at 130 degrees F (54.4 degrees C) electrical outlets with covers over them

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

A public health nurse is providing community education to older adults regarding their risk of poisoning. Which information does the nurse include in the teaching? reviewing hidden sources of lead in the household environment keeping medications in clearly labeled containers using alternatives to chemical-based cleaning supplies avoiding the use of alternative and complementary therapies

keeping medications in clearly labeled containers

Which level of health care provider may make the decision to apply physical restraints to a client? senior personal care assistant LPN team leader nurse practitioner RN nurse manager

nurse practitioner

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

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 one bed rail to offer stabilization when standing placing the client in a bed with a bed alarm providing a bed that is low to the floor raising all side rails while the client is in bed

raising all side rails while the client is in bed

Which nursing concern is appropriate for designing educational interventions for a single parent who leaves their toddler unattended in the bathtub? suffocation risk altered body temperature risk not compliant falls risk

suffocation risk

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 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 and 6-year-old each holding the mother's hand the 2-year-old helping mom to open the front door of the school

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

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 stretchers clamping of clients' suction tubes use of elevators closing of doors and windows

use of elevators

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? ensuring a good ventilation system at the workplace using carbon monoxide detectors and alarms keeping the resuscitation equipment ready at hand educating the workers about signs of the presence of CO gas

using carbon monoxide detectors and alarms

The nurse is assessing clients for risk factors in the workplace. Which client(s) is at risk for injury due to the environment of the workplace? Select all that apply. medical records technician who works in a health care provider's office unlicensed assistive personnel who lifts clients in a long-term care facility worker who operates equipment in an automobile assembly plant owner of a fitness center who teaches one yoga class a day gardener who mows and places fertilizer on lawns

worker who operates equipment in an automobile assembly plant gardener who mows and places fertilizer on lawns