(PrepU) Chapter 27: Safety, Security, and Emergency Preparedness

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death?

Fifth Unintentional injuries are the fifth leading cause of deaths behind heart disease, cancer, stroke, and chronic obstructive lung disease. Listed are the top 3 leading causes of death in the US: Heart disease, cancer, and chronic lower respiratory diseases.

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. The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it.

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 people who die in house fires die of smoke inhalation rather than burns. Most people who die in house fires die of smoke inhalation rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping.

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. The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing.

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 leading cause of injury and death in children 1 to 4 years of age is drowning. Therefore, providing close supervision when children are in or around tubs and pools will help decrease and/or prevent this injury.

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 RACE acronym should be used when managing a fire: Rescue, Alarm, Confine, and Extinguish. Teaching has been effective when the UAP knows to rescue patients first.

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?

"Parents are effective role models for children when they also wear helmets while riding." Parents are effective role models for children when they also wear helmets while riding. Helmets that have been damaged in a crash should not be worn. The chin strap should fit snuggly, not loosely. Young children who are secured in a bicycle passenger seat must also wear a helmet.

The nurse is assessing an adolescent with an annual physical. The parent reports noticing a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The parent does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse?

"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial." Some signs of substance use in adolescents include mood swings, withdrawal from the family, and failing school grades. The other statements are inappropriate generalizations and do not address the problem. There is not enough evidence to suggest a need for hospital admission.

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for a 9-month-old infant?

"We place our baby in a rear-facing car seat in the back seat of the car." Children from birth to 2 years of age should remain in a rear-facing infant seat in the back seat of the car until they reach the maximum height and weight for a front-facing child car seat.

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?

19-year-old male college student majoring in physics Young adults, particularly those who just became emancipated from parental supervision, are at the highest risk for alcohol and drug use. Other clients may have other safety risk factors, but are not at a proportionately higher risk for alcohol and drug use.

Which clients are most at risk for falling due to altered mobility? Select all that apply.

A client with a spinal cord injury An older adult client with an unsteady gait A client who requires crutches in unfamiliar health care settings Limitations in mobility are unsafe and can cause client injury. The nurse should be aware that clients with spinal cord injuries, older adults with unsteady gaits, and clients who require assistive walking devices such as crutches, especially in unfamiliar health care settings, may be at risk for falling. Not all older adults are at risk for falls. Most females who wear heels are not most at risk for falls, even if they had surgery 2 weeks ago.

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. A sentinel event is one in which a client experiences death or serious injury.

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. Electrical shock can result if appliances such as a hair dryer come in contact with water. The hair dryer should be removed away from the sink. Other findings reflect appropriate safety measures.

The 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. RACE stands for Rescue - Alarm - Contain - Extinguish. The "A" in the acronym RACE stands for "activate the fire alarm and notify the appropriate person."

When educating parents about the safety of preschool-aged children, which is most important for the nurse to include in the presentation?

At home chemicals should be kept in a locked cabinet. Increasing mobility, lack of life experience and judgment, and immature musculoskeletal and neurologic systems lead to potentially hazardous encounters for toddlers and preschool-aged children. Parents must be taught to keep chemicals in a locked cabinet to reduce exposure. Weapons should be secure, preferably in locked gun cabinets to prevent access by children. The recommended safety equipment for sports should be used by people of all ages to prevent injury, not to decrease fear.

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

Avoid unattended baths for the toddler. The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious. Monitoring the activities of the toddler is not always feasible. Allowing the child to swim with friends does not ensure safety.

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) The Quality and Safety Education for Nurses (QSEN) project has been designed to provide a framework for the knowledge, skills, and attitudes necessary for future nurses. The six competencies include client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Requirements for foreign-educated nurses and the establishment of clinical career ladders are not explicit focuses of the QSEN competencies.

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

Dangling blind cords As babies gain neurologic and musculoskeletal functions, they learn and explore by pulling objects to themselves and placing almost everything in their mouths. Cords, tablecloths, plastic bags, bottles, and cans are tempting, dangerous objects that caregivers must strive to keep out of reach.

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. The decision tree for treating ingested poisons states that if petroleum is ingested, it should be diluted with water or milk, vomiting should be prevented, hydration should be given, and symptoms should be treated. Therefore, it is not appropriate to call 911, induce vomiting, or administer a laxative.

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment?

Encourage exercise that improves balance and muscle strength Falls are a significant health hazard for the older adult. Regular exercise has a positive effect on bone and muscle strength, balance, and flexibility of joints. A high-fiber, low-fat diet may be advisable for many older adults, but it is not specific to promoting client safety in the home. Information about promoting regular sleep may improve safety for select groups of clients, but will not have the specific benefits for fall prevention achieved by improved balance and muscle strength. Avoiding liquids before bedtime may decrease the need for night time trips to the bathroom, and may be a valid recommendation for some parties. However, the outcome benefits are not as specific to fall prevention in health older adults as exercise, balance, and muscle strength.

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

Have a meeting place outside the home in case of fire. The whole family should regularly practice a fire escape plan, such as crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in an area with access and not a closet.

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.

Headache Vomiting Drowsiness Concussions are a frequently seen sports injury in school-age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present. Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms usually seen with a concussion.

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

Household cleaners must be kept out of reach. Toddlers are naturally inquisitive and more mobile than infants and fail to understand dangers; therefore, it is appropriate to teach parents of toddlers to keep household cleaners out of reach. Teaching about changing table safety is more appropriate for infants. Teaching about protective sporting gear is appropriate for school-age children who are physically active. Teaching about peer pressure is more appropriate for adolescents.

An anxious adult child asks the nurse how to keep an older adult parent safe in the home. The client tells the nurse that the parent lives alone, has chronic illnesses, and also has sensory-perceptual alterations. What is the nurse's first action in forming an intervention plan?

Identify the hazards in the home. A home visit by the nurse or an agent on behalf of the nurse is in order or a home survey to complete by the family. This would help the nurse to identify areas that would need to be addressed. Presence of stairs alone will not help the nurse formulate a plan; however, the presence of stairs may be included in the overall assessment of the home. Assessing the parent's health and mobility may be part of forming an intervention, but identifying the hazards will help the nurse identify what kind of assessments are needed for the parent. Family involvement may become important to know once the interventions are identified.

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

Implement drowning prevention strategies. The principles of injury control have interventions centered at three primary levels: the individual level--providing education about safety hazards and prevention strategies; the design phase--using engineering and environmental controls; and the regulatory level--creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users. Although the nurse's role would fit into the individual level of providing education, it is not the nurse's responsibility to teach cardiopulmonary resuscitation or swimming in this scenario. As the nurse's role does not include the design phase or regulatory level, it is not a nursing responsibility to require fencing around all pools.

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

Initiate use of a bed alarm. To prevent a fall, the nurse should attempt to prevent the confused client from getting out of bed by himself by using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all four side rails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort when the client is in danger of harming himself or others. Contacting the physician for a restraint order or sedative is appropriate if the least restrictive measures do not work.

What best describes the nurse's role in disaster preparedness?

Multiple roles, including triage and the distribution of resources Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources.

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 should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard. Taping the electrical cord to the ground and running the electrical cord under the carpet are not appropriate actions for electrical safety.

The older adult client is confused and wanders at night at home. The caregiver is seeking assistance with this problem. The caregiver states, "I am so worried about my family member. What can I do and still get some rest at night?" What instruction(s) would the nurse provide to the caregiver? Select all that apply.

Reduce stimulation, noise, and light a few hours prior to bedtime. Provide low lights in the rooms in which the client may wander. Encourage the client to toilet prior to bedtime. Place locks on any doors to the outside that the client would be able to open. The nurse would tell the caregiver to reduce stimulation, noise, and light in the hours prior to sleep to encourage relaxation and to set an appropriate bedtime routine. For safety reasons, the caregiver should provide sufficient lighting for the client at night in case the client wanders. Another appropriate bedtime routine is toileting prior to bedtime. For safety reasons, the caregiver can place locks on doors so the client is unable to get through and wander outside. Having the client exercise at night is stimulating and would make it more difficult for the client to fall asleep at night.

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. Extension cords should not be used so that overload is not placed on electric wires and circuits. For safest practices that decrease risk for electric shock, outlets and switches should be covered, machines that are used infrequently should be unplugged, and plugs should be removed from the wall by grasping the actual plug (not the cord).

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

Remove the client from the room. In case of a fire, the nurse should (in this order) rescue anyone in immediate danger, activate the fire code system, notify the appropriate person, and confine the fire by closing doors and windows. Therefore, in this instance, the nurse's first action should be to remove the client from the room.

There is a fire in the trashcan in the client's room. What is the nurse's first priority?

Remove the client from the room. The priority would be to remove the client from immediate danger. The acronym for health care facility fire safety is RACE, which stands for rescue, alarm, confine, and evacuate.

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. In keeping with National Patient Safety Goals, the nurse will read back the order, then proceed to document the order in the EHR, prepare the medication, and identify the client by two identifiers prior to administration.

Upon hourly rounding, a nurse finds that a fire has broken out in a client's room. Which intervention is the priority?

Rescue the client. The first priority in case of fire is to rescue the client. As per the RACE principle of fire management, the rescue of the client is the first step, followed by raising an alarm, confining the fire, and finally, extinguishing the fire.

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 client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets, giving warm bottles of formula to the baby, and keeping all pots and pans in lower cabinets are secondary teachings.

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

Risk for Injury Related to Agitation The client's risk of self-injury or injury to others is the justification for restraint use. Restraints are not normally used to address noncompliance or chronic confusion unless there is a consequent safety risk. Impaired bed mobility is not a justification for restraints.

The nurse is caring for a young child in the hospital who is being discharged home with his grandmother, who has guardianship. When performing a risk assessment, the nurse identifies that his grandmother has one other adult living with her to help with the child, because the grandmother has congestive heart failure and diabetes mellitus. In addition, the financial situation is poor and she cannot afford to buy safety devices to safety-proof the house. What nursing diagnosis is most appropriate for this child based on these findings?

Risk for Poisoning related to medications in unlocked cabinets Because this child lives with his grandmother, who has a diagnosis that requires multiple medications, and because the family cannot purchase safety devices to safety-proof the house, this child is most at risk for poisoning related to medications in unlocked cabinets. There is no evidence that there is peeling paint in the home, or substance use, or that the child is being left unattended.

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

Social pressure As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment.

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 Reasonable measures to avoid the use of restraints must be attempted before implementation; these measures must be documented. Verbal restraint prescriptions must be renewed every 24 hours, not every 48 hours. Neither a detailed description of the restraint application process nor the type of personal protective equipment used by the nurse during restraint application are required to be documented.

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply.

The client is wearing the oxygen around the neck. There is spilled water on the floor. The IV is not infusing at the correct rate. The skin is a bluish-color. The situational assessment includes: ABCs, IVs, tubes, oxygen, safety, and environmental safety, including the nurse's intuition, hearing, smelling, seeing, or feeling that something needs to be explored. The client wearing oxygen around the neck is a concern in a situational assessment, because the client's SpO2 may be decreased if the oxygen is not worn properly. Moreover, tubing around the neck presents a safety issue, as does spilled water on the floor. The client's television is of no importance to the situational assessment. The situational assessment should check whether the IV is infusing at a correct rate. The client's skin being a bluish color is also a concern during situational assessment; it could be related to not wearing the oxygen correctly or indicate coldness or lack of perfusion.

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. If "never events" occur while a client is hospitalized, the cost of the care associated with that event will not be paid by CMS, but will be borne by the hospital. Fines are not levied against the hospital, however, and CMS does not actively divert clients to other facilities. CMS does not pay damages on behalf of hospitals.

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident. An unintentional injury or incident that compromises safety in a health care agency requires the completion of a safety event report (incident report). The nurse completes the event report immediately after the incident and is responsible for recording the circumstances and the effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. The physician is not responsible for filling out or signing the safety report unless she witnessed the incident. The nurse reports factual information, not opinions.

A nurse follows the universal client compact principles for partnership when providing care for clients. Which nursing action reflects this philosophy?

The nurse includes the client as a member of the health care team. The National Patient Safety Foundation's Principles for Partnership represent a concerted effort to demonstrate a health care organization's commitment to respect the rights of clients and incorporate these beliefs into their mission. Including the client and family as a member of the health care team reflects these principles. The other answer choices do not demonstrate these principles.

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 completes the safety event report immediately after an unintentional injury and is responsible for recording the incident and its effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. The nurse should not wait until after the x-ray to complete the form.

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. The client should be released from the restraint as soon as he or she is no longer a risk to self or others. Decisions should be based on the client's present status, not on his or her history. Restraints must be ordered by a health care provider and the least restrictive device should be used.

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. Adolescence is a time of rapid physical growth and more sleep is required. Many adolescents try to balance afterschool activities with jobs and school, resulting in sleep deprivation. This, in turn, poses a safety risk as adolescents have increased freedoms, such as driving.

The assistive personnel has bathed the client who is in restraints. Upon assessing the client on hourly rounds, the nurse determines the client's restraints pose a risk for injury to the client. What assessment(s) represents a rationale for removal or adjustment ? Select all that apply.

Two fingers cannot be inserted between the restraint and the client's extremity. The restraint is tied to the side rail of the bed. To avoid injury, the nurse would correct the distance between the restraint and the client's extremity. The restraint must be snuge such that one to two fingers can be inserted between the restraint and client's extremity. The nurse should be able to insert two fingers to prevent neurovascular damage to that extremity. The nurse would correct the restraint being tied to the side rail of the bed. Injury could occur when the side rail is lowered. The restraint should be tied to the frame of the bed. No correction is required for proper application of the restraints, including the client's extremities being in normal anatomic positions, a quick-release knot being used, and the restraint being out of the client's reach.

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

Use protective sporting equipment. School-age children in the 7th grade are physically active, which makes them prone to play-related injuries. Therefore, protective sporting equipment should be used. Information about not texting while driving is more appropriate for teenagers and adults who drive. Using caution around electrical outlets and stairs is more appropriate for parents of toddlers.

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. If latex gloves are used, nurses should wash hands thoroughly after removing gloves with a pH-balanced soap. They should use powder-free, not powdered, gloves. They should not snap gloves when applying them. They should avoid using oil-based hand creams or lotions.

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 antipsychotic Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint.

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 Chemical restraints are medications, such as an antipsychotic, that are used to manage a client's behavior or freedom of movement. These are generally used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the client, staff, or others. Physical restraints are devices that immobilize or reduce the ability of a client to freely move his or her arms, legs, body, or head. Asking the UAP to sit with the client is a diversion method. Articulation of rationale for using a physical restraint is part of nursing teaching.

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 An older adult with multiple driving infractions may be having difficulty with sensory-perceptual alterations due to aging changes such as glaucoma, cataracts, presbyopia, presbycusis, cognition, or response time impairments. The 12-year-old should not experience sensory issues with a sprain of the wrist. The 42-year-old may be stressed but is not experiencing illness. The 16-year-old is experiencing illness, but it is not a sensory-perceptual alteration.

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

automobile accidents. Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers.

The school nurse is preparing a presentation about safety promotion for middle school-aged students. Which topic will the nurse plan to include?

consistently using seat belts Seat belt use is an important safety precaution for middle school-aged children due to their increased risk for motor vehicle accidents. Improper seat belt use (or lack of seat belt use) increases the risk for injury. It is not appropriate to teach middle school-aged children about moderation with alcohol, because they should be taught about abstaining from alcohol use in general. Workplace injuries and falls do not directly relate to the age group.

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.

drinks 2 shots of alcoholic beverages before dinner climbs two flights of stairway to get to his bedroom takes a diuretic pill early in the morning prefers to use the bathtub when taking a bath Unintentional injuries at home are common for the older adult. Safety habits, no longer reinforced by watchful adults, can become rusty; disregard of judgment, overconfidence, or ignorance can place adults in danger's path. In addition, adults may consume alcohol, which interferes with judgment to interpret the environment and with physical capabilities to operate machinery, thus contributing to injuries.

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 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. Incident reports are primarily used to facilitate improvements, not to determine culpability. A client's health record requires skill to document the necessary behavior and results and allows for adapting nursing care planning; a client health record must not discuss aspects particular to the incident report or facility issues. Holding a meeting will likely be necessary or helpful, but does not replace the need to document the event in the form of an incident report.

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) The nurse will intervene if the hot water heater thermostat is set above 120 degrees F (48.8 degrees C). This could cause burning to an infant's skin. Other findings enhance safety within the home.

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 Older adults often wear slippers to accommodate swollen feet. Although slippers are more comfortable, less expensive, and less tiring to put on than shoes, they do not offer much support or traction. The nurse should intervene to remind the UAP that better footwear should be utilized. Placing the bed at the lowest setting, clearing a path from the bed to the bathroom, and having the client sit in bed before standing increase safety while minimizing risk for falls.

A client is being treated for community-acquired pneumonia and has experienced respiratory distress and hypoxia on several occasions since being admitted. The nurse can best prevent adverse outcomes during this client's care by:

vigilantly monitoring the client's oxygenation status. All of the listed actions are appropriate to the care of this client. However, close monitoring and early detection of changes are paramount in the prevention of adverse outcomes. Frequent and careful assessment is a priority.