Prep U: Chapter 22

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which of the following actions should the nurse take?

pull the fire alarm lever

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.

A nurse is preparing to file a safety event report after a client experienced a fall. The nurse is aware that which statement below 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.

A nurse visits an elderly client at home and assesses the safety of the client's environment. Which of the following articles can be a threat to the client's safety?

Area rugs kept on the stairs without carpet

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

Educating nurses on how to prevent falls

An anxious son asks you how he can keep his elderly father safe in his home. He tells you his father lives alone, has chronic illnesses, and also has sensory-perceptual alterations. What is the best statement by the nurse?

"A good idea is to get a weekly medicine tray at the pharmacy. This will keep him from missing medication doses or taking the wrong pill by accident."

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."

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 staff development nurse is providing an in-service to a group of nurses on the use of restraints in healthcare facilities. Which of the following is an example of a chemical restraint?

A dose of an antipsychotic

Which of the following statements about restraints used in the acute care setting is true?

A physician's order for use of a restraint is valid for 24 hours only.

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 code system and notify the appropriate person.

A nurse is caring for an elderly client at risk of injury due to confusion. The client has a stable gait. Which of the following methods of restraining should the nurse use?

Alarm-activating bracelet

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which of the following clients?

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

A mother is concerned about the safety of her one-and-a-half-year-old toddler. Which of the following would be most appropriate for the nurse to include in the teaching plan for this mother and her child?

Avoid leaving the toddler unattended in bed

Which of the following interventions to prevent patient falls in the acute care setting require collaboration with a patient's primary care provider?

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

Which nursing diagnosis would the nurse select as most appropriate for an adolescent who has been exerting their independence with questionable life choices?

Decisional Conflict related to attending a party with no parental supervision.

A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which of the following is a prudent nursing intervention for this client?

Document the incident, assessment, and interventions in the client's medical record.

A physician orders restraints for a confused client who is at risk for injury by pulling out tubes necessary to sustain her life. Which of the following statements describes an accurate action to take when applying these restraints?

Ensure that two fingers can be inserted between the restraint and the client's extremity

A geriatric patient has been receiving care in a two-bed room that he has shared with another older, male patient for the past several days. Two days ago, the patient's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the patient himself was awoken early by similar diarrhea. The patient may have developed which of the following types of infections?

Exogenous nosocomial

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

Experimentation with drugs and inhalants

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

Get the victim out of the present environment

What safety device for children is mandated by law in all 50 states?

Infant car seats and carriers

A nurse is educating a mother about caring for a newborn baby. What should the nurse teach the client as a precautionary measure to protect the infant from burns?

Keep hot substances away from the baby

A nurse is caring for a stable toddler diagnosed with accidental poisoning, due to the ingestion of cleaning solution. What must be included in educating parents about how to protect a toddler from accidental poisoning?

Keeping cleaning solutions locked up

A nurse is preparing to provide care to a client who is receiving radiation therapy for cancer in which the radiation source will be kept in the client's room. Which of the following would be most important for the nurse to do?

Limit own exposure to radiation for the minimum time

Nurses provide many interventions to prevent falls in health care settings. Which of the following would be an appropriate intervention to prevent falls?

Lock wheels on beds and wheelchairs.

What would be the best restraint to use on an infant during care for a head wound?

Mummy restraint

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

Nurse Practitioner

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which of the following interventions should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter.

A nurse is admitting a client to a geriatric medicine unit following the client's recent diagnosis of acute renal failure. Which of the following nursing actions is most likely to reduce the client's chance of experiencing a fall while on the unit?

Orient the client to the room and environment thoroughly upon admission.

Mr. Ames, age 84, has just been admitted to the hospital for the treatment of pneumonia. In addition to this diagnosis, Mr. Ames also has stage II Alzheimer's disease and is disoriented to place and time. As the night has progressed, he has become increasingly agitated, pulling out his intravenous catheter and wandering throughout the unit. He has become more agitated as the nurses have attempted to reorient and redirect him. Which of the following interventions should the nurses perform?

Position Mr. Ames' bed closer to the nurses' station and perform an assessment

A nurse is assigned to care for a hospitalized toddler. Which of the following activities should be the highest priority for the nurse?

Protect the toddler from injury

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 of the following measures does not comply with a least restraint policy?

Raising all side rails while the client is in bed

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.

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

Restrain the baby in a car seat.

The nurse is following the Joint Commission's national patient safety goals when giving medications. Based on these goals, how can the nurse improve the accuracy of patient identification?

Use two patient identifiers (neither to be the room number).

A team of inner city school nurses attends a community conference on child safety during the summer months. Which of the following 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.

In light of the failure of alternatives, a nurse has been forced to physically restrain an agitated client. Which of the following actions should the nurse perform when applying and maintaining the restraints?

Tie the client's hand restraint to the bed frame rather than the side rail.

There is a fire in the neurology unit of a healthcare facility. Which of the following would be most appropriate to avoid in this situation?

Use of elevators

The charge nurse is observing a new nurse care for a patient who is at high risk for falls. Which of the following actions by the new nurse would require the charge nurse to intervene?

Waiting outside of the closed bathroom door while the patient uses the toilet

What age group is most vulnerable to toxic fumes or asphyxiation?

Young children

A home care nurse provides health education to parents regarding the care of their toddler. Which of the following precautions should the nurse suggest the parents take to protect the toddler from drowning?

avoid unattended baths

A nurse is providing an inservice 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?

electrical fire

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

true