safety exam

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."

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."

Which nurse would be at the highest risk of causing a hazardous situation? A nurse who has worked 32 hours of overtime this week A nurse who has placed a client in the bed with three side rails up A nurse who is transferred to another unit to assist with care A nurse who is administering medications to four clients

A nurse who has worked 32 hours of overtime this week

A school-age child is admitted to the emergency room with the diagnosis of a 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

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?"

What teaching will the community health nurse include for parents of toddlers? Place the child securely on a changing table. Household cleaners must be kept out of reach. Purchase protective sporting equipment. Peer pressure can contribute to risk-taking.

Household cleaners must be kept out of reach. 765

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? Impaired Bed Mobility Related to Muscle Wasting Noncompliance Related to Medication Regimen Risk for Injury Related to Agitation Chronic Confusion Related to Long-Standing Alcohol Use

Risk for Injury Related to Agitation

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.

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.

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.

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. 775

A school nurse is teaching a group of adolescents about safe driving. What behavior(s) should the nurse encourage to help prevent motor vehicle accidents? Select all that apply. Always wear a seat belt. Drive at night when fewer people are on the road. Limit the number of other adolescents in the car. Never text while driving. Obey the speed limit.

Limit the number of other adolescents in the car. Never text while driving. Obey the speed limit. 769

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 fatal home fires occur while people are cooking. About 10% of home fire deaths occur in a home without a smoke detector. Most home fires are caused by children playing with matches.

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

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. 784-785

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. 776

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.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? Sedate her with sleeping pills and leave the restraints on. Take the restraints off, stay with her, and talk gently to her. Leave the restraints on and talk with her, explaining that she must calm down. Talk with the client's family about taking her home because she is out of control.

Take the restraints off, stay with her, and talk gently to her.

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 788-89

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

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 Suggest a high-fiber, low-fat diet Provide a pamphlet on maintaining healthy sleep habits Restrict consumption of liquids before bedtime

encourage exercise that improves muscle balance and strength

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

provides slippers for ambulation 784-786

A nurse failed to document the administration of a client's warfarin and the nurse on the next shift administered the drug again, believing that it had been overlooked. When performing root cause analysis, what question should be asked first? "Has this, or something very similar, ever happened on the unit before?" "Why did the second nurse administer this drug to the client?" "What could the two nurses have done to ensure this did not happen?" "What were the possible adverse outcomes that could have resulted from this error?"

what could the two nurses have done to ensure this did not happen?

A hospital is introducing a program that has the goal of aligning practices more closely with the Quality and Safety Education for Nurses (QSEN) project. What initiative best exemplifies QSEN competencies? New systems are introduced to increase communication between nurses and the members of other health disciplines. Systems are reviewed with the goal of achieving the best client outcomes at the lowest cost. Hiring practices are reviewed to maximize the proportion of nurses who possess baccalaureate or graduate degrees. New partnerships are established between the hospital and local schools of nursing.

New systems are introduced to increase communication between nurses and the members of other health disciplines. 753

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? Past experience Poor judgment Social pressure Normal rebellion

Social pressure

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? Leave to notify the health care provider concerning a change in client status Apply limb restraints to ensure client safety Promptly document the change in client status Reduce distressing environmental stimuli to maximize client safety

Reduce distressing environmental stimuli to maximize client safety