PrepU 27- part 2
The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate?
Identifies clients full name and date of birth
A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?
Obtain a three-prong grounded plug adapter
The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?
The alternative measures attempted before applying the restraints
The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client?
The client will not experience a fall and remains free of injury.
A nurse is preparing to file a safety event report after a client experienced a fall. Which statement 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.
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?
administration of an antipsychotic agent to alter the client's behavior
Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?
"Always provide close supervision for young children when they are in or around pools and bathtubs."
The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.
1- Client-centered care 2- Teamwork and collaboration 3- Quality improvement (QI)
A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.
1- Drowsiness 2- Headache 3- vomitting
The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?
Ask to examine the client alone in order to speak to her privately
A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?
Conceal IV tubing with gauze wrap
Which item would alert the home care nurse to a safety hazard threatening a young child?
Dangling blind cords
A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?
Flush the eyes with water for 10 minutes.
An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls?
Provide a bedside commode and ensure adequate lighting.
What is the primary role of the nurse in the care of clients who experience domestic violence?
Providing prompt recognition of the potential or actual threat to safety
A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?
Pull the fire alarm lever (RACE)
An older adult client has developed diabetic neuropathy. What would be the most important education intervention for the client and family?
Reduce the temperature on the water heater.
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 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 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.
1- Remove extension cords from open spaces. 2- Check the batteries in all smoke detectors. 3- Ensure appropriate lighting in hallways and entrances to the home. 4- Remove throw rugs from high traffic areas.
The nurse is caring for a school-age child and notices a variety of circular burns on the back and legs in various stages of healing. What action should the nurse take related to this suspicion?
Notify the National Abuse Hotline
An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first?
Reduce distressing environmental stimuli to maximize client safety
A nurse is preparing discharge education for a client with a newborn infant. What is the highest priority item that must be included in the education plan?
Restrain infant in a car seat
A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the 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 injury.
A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?
Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.
