PrepU Chapter 27: Safety, Security, and Emergency Preparedness
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? -Instruct the toddler not to go near the pool. -Avoid unattended baths for the toddler. -Monitor the activities of the toddler. -Allow the child to swim with friends.
Avoid unattended baths for the toddler. Explanation: 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 is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include? -Supervise your child on the changing table. -Keep medications out of reach. -Buy protective sporting equipment. -Peer pressure causes children of this age to take risks.
Supervise your child on the changing table. Explanation: Infants should be supervised on a changing table. Therefore, it is appropriate to tell the caregiver to supervise the child on the changing table. The other options are not appropriate for infants, but are more appropriate for older children.
Which item would alert the home care nurse to a safety hazard threatening a young child? -Three blankets in a crib -A gated stairway -Padded child safety seat -Dangling blind cords
Dangling blind cords Explanation: 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.
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." -"Never smoke in the bed in the house when young children are present." -"Store medications in a locked area to prevent children from getting into them." -"Never keep firearms in the home with young children."
"Always provide close supervision for young children when they are in or around pools and bathtubs." Explanation: 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 poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse? -"Check breathing and heart rate." -"What do you think that the child might have ingested?" -"At what time did the child ingest the substance?" -"Induce vomiting while you wait for emergency personnel to arrive."
"Check breathing and heart rate." Explanation: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function. After that, rescuers attempt to identify what was ingested, how much, and when. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach.
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." -"I will sound the alarm before I start moving a patient from a room." -"I will leave all doors open after rescuing patients." -"I know that nurses are the only ones who can extinguish a fire."
"I will rescue clients from harm before doing anything else." Explanation: 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 visits an older adult client at home and assesses the safety of the client's environment. Multiple small rugs are located in the home. Which statement by the nurse is appropriate when addressing the client's safety? -"Your home needs to be a safe environment as older adults have a tendency to fall." -"I think you should replace your small rugs with skid-resistant rugs on the floor." -"I am concerned that the small rugs in your home can be a tripping hazard." -"You need to remove the small rugs from your house or you will fall."
"I am concerned that the small rugs in your home can be a tripping hazard." Explanation: The nurse can open up the conversation by stating concern about the small rugs. The conversation provides education through problem-solving. If the nurse demands or states generalities, the nurse will not gain the needed cooperation from the client. The older adult client should remove all area rugs, even if skid resistant, to prevent accidental injury.
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? -"Did you leave the household chemical in reach of your child?" -"Is your child breathing at this time?" -"You should not have left your child alone while you showered." -"Induce vomiting and call 911 right away."
"Is your child breathing at this time?" Explanation: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function, so the nurse will ask about the child's respiratory status. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach; vomiting should not be induced until more information is gathered. Instructing the parent about leaving the child alone is not therapeutic at this time.
A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety? -"Any helmet is appropriate for bicycle riding because all children should wear helmets when riding." -"Parents are effective role models for children when they also wear helmets while riding." -"The chin strap on the helmet should be adjusted to fit loosely so that it does not choke the child." -"Young children secured in a bicycle passenger seat do not have to wear a helmet."
"Parents are effective role models for children when they also wear helmets while riding." Explanation: 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? -"Adolescents are generally difficult children. Sometimes punishment is necessary to make them change their attitudes." -"Let's admit your child to an acute care facility so that we can run more tests." -"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial." -"This is typical adolescent behavior. Ignore it and it will improve."
"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial." EXPLANATION: 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.
The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client? -"It is important to us that you remain free from injury." -"You will mostly stay in bed while you are hospitalized." -"Use the call bell for any needs and wear nonslip footwear." -"Do not get up without assistance for any reason."
"Use the call bell for any needs and wear nonslip footwear." Explanation: All of these teaching points are correct. However, the best action is for the nurse to teach the client how to be safe by using the call bell for assistance and wearing nonskid footwear. Telling the client that it is important for the nurse that the client remains free from injury is true, but this statement does not inform the client how to avoid becoming injured in this new environment. The client may remain in bed for a large portion of the stay, but the client will need to get up and should be taught how to safely do that. Instructing the client to not get out of bed for any reason is not healthy for the postoperative client, and it is not reasonable. Rather, the nurse teaches the client how to be safe when getting up.
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. -Drowsiness -Fever -Headache -Increased thirst -Vomiting
-Headache -Vomiting -Drowsiness Explanation: 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.
The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply. -Communication ability -Community population -Developmental level -Mobility -Type of health care facility
-Mobility -Communication ability -Developmental level
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. -Check the batteries in all smoke detectors. -Store prescription medications on the counter. -Ensure appropriate lighting in hallways and entrances to the home. -Remove throw rugs from high traffic areas.
-Remove extension cords from open spaces. -Check the batteries in all smoke detectors. -Ensure appropriate lighting in hallways and entrances to the home. -Remove throw rugs from high traffic areas. Explanation: Nursing assessment includes identifying individuals at risk and recognizing unsafe situations in the environment. Assessment includes an awareness of risk factors in the home. The nurse would advise the client to remove extension cords from open spaces, check the batteries in smoke detectors, remove throw rugs, and ensure appropriate lighting in hallways and entrances to the home. The nurse would not advise the client to place prescription medications on the counter as anyone could access these. It is recommended that medication be kept in a place that is easy for the client to access, but still should be kept out of the reach of children or others who may take them.
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. Explanation: 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 nurse is caring for an acutely confused hospital client who is ordered to remain on bed rest for medical reasons. The nurse asks the health care provider for an order for restraints. Which guidelines for the use of restraints should the nurse follow? Select all that apply.
-The client's family must be involved in the decision and care plan. -Alternatives to restraints and less restrictive interventions must have been implemented and failed. -The benefit gained from using a restraint must outweigh the known risks for that client. EXPLANATION The client has the right to be free from restraints that are not medically necessary. Restraints are not used for the convenience of staff or to punish a client. The client's family must be involved in the care plan and must be consulted when the decision is made to use restraints. Alternatives to restraints and less restrictive interventions must have been implemented and failed, and all alternatives used must be documented. The benefit gained from using a restraint must outweigh the known risks for that client. A physician or licensed independent practitioner must reevaluate and assess the client every 24 hours. The client's vital signs must be assessed and the medical client must be visually observed every 2 hours.
A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply.
-Use filtering software to block objectionable information. -Investigate any public chat rooms used by the children. -Be alert for downloaded files with suffixes that indicate images or pictures. Explanation: Parents should keep identifying information private (e.g., full name, address, telephone number) and investigate filtering software or methods of blocking out objectionable information. They should warn their children to avoid public chat rooms and forums and emphasize that everything said or anything read online may not be true. They should also be alert for downloaded files with suffixes that indicate images or pictures (e.g., .jpg, .gif, .bmp, .tif, .pcx) and consider keeping the computer in a central location in the house, rather than in a child's bedroom (USAA Educational Foundation, 2009).
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.
-takes a diuretic pill early in the morning -climbs two flights of stairway to get to his bedroom -prefers to use the bathtub when taking a bath -drinks 2 shots of alcoholic beverages before dinner Explanation: 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 arrives at the emergency department after an industrial explosion involving an unknown chemical contaminant. What is the nurse's priority action? -Assess client's respiratory depth and effort -Activate external disaster protocol -Identify chemical agent before treating -Flush skin while rinsing with sterile saline
Activate external disaster protocol Explanation: Before performing assessments or interventions, it is essential that the nurse inform others about the incident in order to mobilize assistance. In most cases, this involves the activation of an emergency protocol.
A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse? -Perform a vision test with Snellen chart -Arrange an audiology consult to evaluate hearing -Assess the client for signs and symptoms of osteoporosis -Arrange for a skilled home care assessment
Arrange for a skilled home care assessment Explanation: The client's home should be evaluated for potential hazards and risks. There is no indication of vision or hearing issues. It is uncommon for falls to be directly attributable to osteoporosis.
The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? -Assess the need for assistance with ambulation. -Put the client's bedside rails up. -Apply socks to the client's feet. -Arrange furniture so that the client has something to hold on to.
Assess the need for assistance with ambulation. Explanation: The diverse physiologic and psychologic capabilities of people and encounters with various safety hazards across the lifespan put various age groups at risk for different safety concerns and potential injuries. Older adult clients are at a higher risk for falling. Thus, the nurse should assess the client's ability to ambulate independently before allowing the client to go to the restroom and to provide assistance, if needed. The nurse would lower, not raise, the bedside rails before having the client exit the bed. The nurse would put nonskid footwear like slippers, not socks, on the client to help prevent falls. Furniture should be arranged so that the client has a clear and easy path to the restroom.
A school-age child is admitted to the emergency room with a possible concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client? -Assessment of head circumference -Assessment of vital signs and respiratory status -Evaluation of all of his cranial nerves -Initiation of a peripheral intravenous (IV) line for fluid administration
Assessment of vital signs and respiratory status EXPLANATION: Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation. Therefore, assessment of vital signs and respiratory status is a priority for this client. Head circumference is only beneficial in children less than 2 years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment. Assessment comes before intervention in the nursing process and more assessment is needed for this client before the need for an IV line is determined.
What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household? -Avoid stuffed animals and blankets in the crib. -Educate about, and be aware of, signs of risky behaviors. -Include safeguards to prevent falls in the home. -Teach seat belt safety.
Avoid stuffed animals and blankets in the crib. EXPLANATION: Suffocation is a hazard for infants, especially before the age of 4 months. Toddlers and older children are more at risk for falls, and adolescents tend to engage in risky behaviors. Therefore, education about, and awareness of, these behaviors is important in this age group, but not for an infant. Seat belt safety is more appropriate to teach older children and adults. Car seat safety would be important for families with a newborn infant.
A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan? -Childproofing the house -Smoking cessation -Safety equipment for playing sports -Back to sleep guidelines
Childproofing the house. Explanation: To prevent accidental injury and death in toddlers and preschoolers, parents need to childproof the home environment. Play areas should allow for exploration but still provide for safety. Safety equipment for sports should be taught to school-age and older children. Drug and alcohol education is also typical for school-age and older children. Back to sleep guidelines are relevant for neonates unable to roll independently.
A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? -Request a sedative from health care provider -Conceal IV tubing with gauze wrap -Ask visiting family member to stay -Assure bed alarms are activated
Conceal IV tubing with gauze wrap. Explanation: Wrapping the IV line provides protection for the site. Medications used to control behavior can be considered a chemical restraint that is an intervention of last resort. The presence of a family member may assure client safety and alleviate client anxiety, but would not necessarily protect the IV site. As well, it is inappropriate to delegate client safety observation to family members. Bed alarms alert the nurse to the client leaving his or her bed, but not interference with the IV site.
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? -Wash the eyes with a hypertonic solution for at least 30 minutes. -Advise the client to avoid blinking until after the eyes are irrigated. -Flush the eyes with water for 10 minutes. -Flush the eyes with a cool saline solution for a 10-minute period.
Flush the eyes with water for 10 minutes. Explanation: If poisonous substances have been instilled into the eye, immediate irrigation with lukewarm water for 10 to 15 minutes may reduce harmful effects.
One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic? -Educate children in cardiopulmonary resuscitation. -Begin swim lessons with toddlers. -Implement drowning prevention strategies. -Require fencing around all pools.
Implement drowning prevention strategies. Explanation: 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? -Contact the physician for a restraint order. -Administer the client's sedative as ordered. -Put up all four side rails on the bed. -Initiate use of a bed alarm.
Initiate use of a bed alarm. Explanation: 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.
A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? -Investigate the possibility of discontinuing his or her catheter. -Limit the resident's fluid intake in order to reduce his or her urge to void. -Collaborate with the resident's health care provider to have his or her diuretics discontinued. -Increase the resident's physical activity to reduce evening restlessness.
Investigate the possibility of discontinuing his or her catheter. Explanaation: Discontinuing the catheter, if medically prudent, would eliminate the risks associated with the resident's behavior. Limiting fluid intake or reducing diuretics would be unsafe and ineffective. Similarly, increasing the resident's activity is unlikely to reduce restlessness.
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? -Evacuate the unit. -Pull the fire alarm lever. -Confine the fire. -Extinguish the fire.
Pull the fire alarm lever. EXPLANATION: 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.
What is the rationale for health care personnel to orient clients to rooms and equipment when they are admitted to the hospital? -It is hospital policy. -It is part of the routine and is included on the admission checklist. -It allows time for the health care provider to write admission orders. -Orienting clients to the surroundings decreases the potential for injury.
Orienting clients to the surroundings decreases the potential for injury. Explanation: Orienting the client to unfamiliar surroundings will decrease the risks for unintentional injury.
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. -Obtain an order for insertion of an indwelling urinary catheter. -Limit the client's fluid intake during the evening. -Accompany the client to the bathroom every 4 hours around the clock.
Provide a bedside commode and ensure adequate lighting. The use of a commode can often reduce the risk of falls that is associated with ambulating to the bathroom. Falls reduction is not considered a justifiable rationale for catheter insertion. Toileting every 4 hours may or may not be adequate for the client's needs. Fluid intake should never be reduced for the sole purpose of reducing urine output.
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. -Evacuate clients and staff. -Activate the fire alarm on the unit. -Attempt to extinguish the fire.
Rescue anyone who is in immediate danger. Explanation: The acronym "RACE" can be used as a guide to the immediate response to fire. This involves rescuing anyone in immediate danger (R); pulling the alarm, calling "code red," and alerting appropriate personnel (A); confining the fire by closing doors and windows (C); evacuating clients and other people to a safe area (E). Extinguishing the fire is not part of the immediate response.
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. -Evacuate clients and staff. -Activate the fire alarm on the unit. -Attempt to extinguish the fire.
Rescue anyone who is in immediate danger. Explanation: The acronym "RACE" can be used as a guide to the immediate response to fire. This involves rescuing anyone in immediate danger (R); pulling the alarm, calling "code red," and alerting appropriate personnel (A); confining the fire by closing doors and windows (C); evacuating clients and other people to a safe area (E). Extinguishing the fire is not part of the immediate response.
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? -Lock all cabinets that contain cleaning supplies. -Keep all pots and pans in lower cabinets. -Give warm bottles of formula to the baby. -Restrain the baby in a car seat.
Restrain the baby in a car seat. Explanation 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 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 Contamination related to flaking or peeling of paint -Risk for Injury related to substance use -Risk for Poisoning related to medications in unlocked cabinets -Risk for Suffocation related to a child left unattended in the bathtub
Risk for Poisoning related to medications in unlocked cabinets EXPLANATION: 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.
The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care? -Risk for Falls related to immobility -Risk for Injury related to substance use -Risk for Poisoning related to poor eyesight and the inability to read medication labels -Altered Sensory Perception related to decreased visual acuity
Risk for Poisoning related to poor eyesight and the inability to read medication labels EXPLANATION: Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in reading the labels of the multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance use in this client.
A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk? -She may be the victim of cyber-bullying. -She has lost interest in academics because she has a boyfriend now. -She may be beginning her menses. -She may be developing nutritional deficiencies from poor dietary habits.
She may be the victim of cyber-bullying. Explanation: Symptoms of cyber-bullying include faltering school achievement, absenteeism, health concerns, isolating oneself from peers/friends, and increased anxiety and depression symptoms. Adolescents may neglect academics when involved in personal relationships, but that is a common milestone of the age group. Achieving menarche may alter mood, but it is not a risk concern. Nutritional deficits can be seen in adolescence and may need to be investigated with this client, but it is not the priority at this time.
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 -A verbal prescription for the restraints, renewed every 48 hours -A detailed description of the restraint application process -The type of personal protective equipment used by the nurse during restraint application
The alternative measures attempted before applying the restraints. Explanation: 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.
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. -The hospital will be fined by CMS because the client developed a pressure injury. -CMS will bear the hospital's costs if the client chooses to sue the hospital. -CMS may choose to divert clients to other health care facilities in the future.
The hospital must bear any costs incurred for treating the client's injury. EXPLANATION 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 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 notify the primary care physician about the bruises. -The nurse should contact the facility's social services department. -The nurse should question the client about the source of the bruises. -The nurse should request permission from the client to photograph the bruises.
The nurse should question the client about the source of the bruises. Explanation: 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 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 should include a note on the client's chart that mentions the report. -The nurse should await results of the x-ray before filing the report. -The nurse should make a copy of the safety event report and place it in the client's medical record.
The nurse should record the incident in the client's medical record and fill out a safety event report separately. Explanation: 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? -Respond to the past history of the client (including previous falls) to determine the need for restraints. -Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. -Individualize the use of restraints and choose the most easily used device. -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.
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. EXPLANATION: 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.
Which factor is related to the highest proportion of falls in long-term care settings? -Toileting -Agitation -Polypharmacy -Impaired sleep patterns
Toileting Explanation: More than 42% of falls in an acute care agency were toileting related, often involving getting out of bed or ambulating to the bathroom, slipping from the toilet or commode, or standing to use the urinal. This exceeds the role of other variables, including agitation, polypharmacy and impaired sleep.
The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include? -the use of skid-proof mats for the bath tub -safety of guns in the home -correct placement of booster seats for the car -Use of blankets, pillows, and stuffed animals in the crib
Use of blankets, pillows, and stuffed animals in the crib Explanation: Infant safety education should include use of approved car seats and not booster seats. Booster seats are used for the pre-school child with recommended height and weight. The use of skid-proof mats in the bathtub are topics more suited to the parents of preschool children. Infants are not likely to be physically able to access guns in the home. Infants should not have pillows, stuffed animals, or blankets in the bed due to the risk of suffocation.
A nurse is caring for an 18-month-old client after a tracheostomy. The client is recovering well and noted a desire to be more active. The nurse selects a toy from the playroom for the client to play with. Which toy is most developmentally appropriate? -a beaded bracelet -dominos -a rocking horse -marbles
a rocking horse Explanation: All of these toys present a choking hazard except for the rocking horse. Rocking horses are a great toy for development of leg muscles.
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: -complete an incident report to determine who was primarily responsible for the event. -document strategies in the client's health record for preventing future incidents. -fill out an incident report, with the goal of preventing a similar event in the future. -hold a facility-wide meeting to identify strategies for making improvements to the safety of residents.
fill out an incident report, with the goal of preventing a similar event in the future. Explanation 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.
Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning? -keeping medications in clearly labeled containers -alternatives to chemical-based cleaning supplies -hidden sources of lead in the household environment -avoiding the use of alternative and complementary therapies
keeping medications in clearly labeled containers. EXPLANATION: Medication overdoses are among the more common sources of poisoning in older adults, a phenomenon that can be reduced by ensuring that medications are in clearly labeled containers to avoid administration errors. Cleaning supplies and lead are more significant sources of poisoning in infants and children. Alternative and complementary therapies carry risks, but it would be unnecessary to recommend complete avoidance of all such therapies.
A school nurse is preparing an education session on safety for parents of school-age children. What would be an appropriate topic for this age group? -selecting toys for the developmental level -providing drug, alcohol, and sexuality education -teaching stress reduction techniques -providing close supervision to prevent injuries
providing drug, alcohol, and sexuality education Explanation: The school-age child should be taught drug, alcohol, and sexuality education. Selecting toys for the developmental level applies to infants. Teaching stress reduction techniques applies to adults. Providing close supervision to prevent injuries applies to toddlers.
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 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 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. Explanation: Windows pose a serious risk to toddlers. Screens can easily give way to the weight of a toddler. This is an unsafe behavior. Toddlers thrive in exploration. The parent must be fastidious in monitoring and helping the toddler accomplish tasks. The buddy system is a great safety tool for school-age children.
