Safety NCLEX

The nurse manager reviewing the purposes for applying restraints to a client determines that further education is necessary when a nursing staff member makes which statement supporting the use of a restraint?

"At night it keeps the client in bed instead of wandering about."

A client with a short leg plaster cast reports intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which statement by the client indicates an understanding of the measures used to relieve the itching?

"I can use a hair dryer on the low setting and allow the air to blow into the cast."

The nurse is preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse instructs the client about this treatment. Which statement by the client indicates adequate understanding of cold therapy treatment?

"I should wrap the frozen ice pack in a towel to help adjust to the cold."

The nurse is discussing the home environment with a hospitalized client preparing for discharge to determine if there are any fire hazards in the home. Which statement by the client suggests a need for follow-up by the nurse?

"I use smoke detectors and change the batteries faithfully every 2 years."

The nurse assesses the environmental safety of a client receiving home oxygen therapy. Which observation by the nurse indicates that the client needs further teaching to ensure safety?

Oxygen concentrator propped against a wall

The nurse is discussing the home environment with a client preparing for discharge to determine whether there are any fire hazards in the home. Which statement by the client indicates the need for further teaching?

"My space heaters are located right next to the walls to avoid safety hazards."

The nurse develops a plan of care for a client who will be hospitalized for insertion of an internal cervical (vaginal) radiation implant. Which intervention should the nurse include in the plan of care for the client?

Place a radiation sign on the door of the client's room.

A home care nurse is visiting an older client recovering from a mild stroke affecting the left side. The client lives alone but receives regular assistance from the daughter and son, who both live within 10 miles. To assess for risk factors related to safety, which actions should the nurse take? Select all that apply.

1. Assess the client's visual acuity. 2. Observe the client's gait and posture. 3. Evaluate the client's muscle strength. 4. Look for any hazards in the home care environment.

A client with coronary artery disease diagnosed with fibromyalgia has not achieved pain relief with opioid pain medication. Which medication should the nurse anticipate being prescribed in conjunction with the opioid pain medication? Select all that apply.

1. Duloxetine 30 mg daily orally 2. Alprazolam 1 mg twice a day orally 3. Pregabalin 75 mg twice a day orally

The nurse is completing an assessment for a client being admitted with suspected seizure activity. The client acknowledges the use of the herbal supplement ginkgo biloba. Which follow-up questions by the nurse would be most appropriate? Select all that apply.

1.Do you have a history of seizures? 2.Do you have a history of a clotting disorder? 3.How long have you been using this supplement? 4.Have you been diagnosed with diabetes mellitus?

The nurse is assessing an older client's risk for falls. Which factors place the client at the most risk of falling? Select all that apply.

1.Use of a walker 2.Bilateral cataracts 3.Use of nitroglycerin 4.Episodes of dizziness

A client asks the clinic nurse about a natural supplement, called elderberry (Sambucus nigra), and what it is used for. Which condition should the nurse tell the client that this supplement has been primarily used to treat?

Colds

The nurse is assessing the environmental safety for a client receiving home oxygen therapy. The nurse determines which observation is within the principles of safe oxygen use?

A "No Smoking" sign is placed in the front window of the client's home.

The nurse should assign a client who is scheduled for the implantation of a sealed internal radiation source to which hospital room?

A single room at the distant end of the hall

The nurse discovers that a fire has occurred in the client's wastebasket. After removing the client from the room, what is the nurse's next action?

Activating the fire alarm

A client has been taught to use a walker to aid in mobility after internal fixation of a hip fracture. After which observation should the nurse determine that the client needs further teaching on how to use the walker correctly?

Advances the walker with reciprocal motion

The nurse enters a laundry room to empty a bag of dirty linens and discovers a fire in the laundry room. The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher to extinguish the fire. The nurse prepares to use the fire extinguisher by first doing which action?

Pulling the pin on the fire extinguisher

The nurse assists the postoperative client with transferring to a chair. Which should the nurse implement to best help maintain the client's center of gravity?

Align the client's feet as wide as his hips.

The nurse is caring for a client who has had wrist restraints applied. Which nursing intervention should receive priority with regard to the wrist restraints?

Assessing color, sensation, and pulses distal to the restraint

A child who had a tonsillectomy has wrist restraints in place to prevent pulling on the intravenous line. The nurse prepares a plan of care and determines that which nursing intervention should receive priority regarding the restraints?

Assessing color, sensation, and pulses distal to the restraints

A client was brought to the emergency department for a possible medication overdose. The client is now responsive and thrashing around. Which action by the nurse is a priority to keep the client safe?

Assign a staff member to stay with the client at all times.

A mother of a 6-year-old child calls the nurse who lives in the neighborhood and tells the nurse that her child accidentally rubbed waterproof sunscreen in his eyes. Which action should the nurse tell the mother to do immediately?

Call the poison control center.

The nurse, after administering an injection to a client, accidentally drops the syringe on the floor. Which nursing action is most appropriate in this situation?

Carefully pick up the syringe from the floor and dispose of it in a sharps container.

The nurse is assisting with the transfer of a client from the operating room table to a stretcher. Which interventions should the nurse implement to ensure client safety? Select all that apply.

Check the client's level of consciousness. Check wheel locks of the operating room table. Raise side rails after the client is positioned on the stretcher per agency policy.

The nurse should implement which safety measures to prevent an electrical shock when using electrical equipment? Select all that apply.

Check the electrical cord for fraying. Keep the electrical cord away from the sink. Disconnect the electrical cord from the wall socket when cleaning the equipment.

To ensure client safety, which assessment is most important for the nurse to make before advancing a client from liquid to solid food?

Chewing ability

In the middle of bathing a client, the unit secretary notifies the nurse that there is an emergency telephone call. Which action should the nurse implement to best assure client safety?

Cover the client, place the call light within reach, and then leave to answer the call.

The unit secretary interrupts the nurse who is with a client and in the process of a bed bath for an emergency phone call. Which interventions should the nurse implement to assure the client's safety? Select all that apply.

Cover the client. Plan to answer the phone call. Place the call light within the client's reach.

The client with a diagnosis of bladder cancer is to undergo weekly intravesical chemotherapy for the next 8 weeks. Which statement by the client should indicate to the nurse that the client understands how to manage urine as a biohazard?

Disinfect the toilet with household bleach after voiding for 6 hours after a treatment.

The nurse assesses a peripheral intravenous (IV) dressing and notes that it is damp and the tape is loose. What action should the nurse take initially?

Ensure all IV tubing connections are tight.

The nurse evaluates the patency of a peripheral intravenous (IV) site and suspects an infiltration. Which action should the nurse take to determine if the IV has infiltrated?

Gently palpate regional tissue for edema and coolness.

The nurse is preparing to change the linens and gown of a client who received an unsealed radiation source earlier in the day for treatment of breast cancer. Which protective items should the nurse wear?

Gown and gloves

When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.

Having suction equipment readily available. Assisting the client to ambulate in the hallway. Monitoring the client closely while showering. Locking the client's bed in its lowest position

The nurse is assessing the client's use of complementary and alternative medicine (CAM). The nurse should be most concerned with the client who uses which CAMs? Select all that apply.

Homeopathy. Herbal supplements

The nurse is preparing to care for a pediatric client with an intravenous (IV) infusion running. Which item should the nurse implement as the most effective means of preventing fluid overload in this client?

Infusion pump

The home care nurse has instructed a client in safety measures for using oxygen in the home. The nurse determines that the client needs further teaching if the client states that he or she should take which action?

Keep the oxygen concentrator as close to the room wall as possible.

The nurse is caring for a client diagnosed with cervical cancer who is receiving brachytherapy. Which equipment should the nurse place at the client's bedside to prevent unnecessary radiation exposure?

Long-handled forceps

A client with a head injury and a feeding tube continuously tries to remove the tube. The nurse contacts the primary health care provider who prescribes the use of restraints. After checking the agency's policy and procedure regarding the use of restraints, the nurse uses which method in restraining the client?

Mitten

The nurse is called by a group of neighbors to the scene of a rural house fire where a person fell down the stairs headfirst trying to escape the fire. The house is filling with smoke. Which priority action should the nurse implement?

Move the victim by holding the head and neck in a neutral position.

The nurse prepares to ambulate a client with left-side weakness. Which position is the safest for the nurse when assisting the client to stand?

On the affected side of the client

The nurse is assigned to care for a child who is at risk of aspiration. The nurse should determine that which indicates best how to safely position this child?

Placing the client side-lying while sleeping

A client is being verbally abusive to the nurse. Which actions should the nurse implement to minimize the risk of injury for the client and staff? Select all that apply.

Remain calm and reassuring at all times. Begin attempts to de-escalate the situation. Obtain assistance from the security department. Visualize an escape route in case the client becomes violent.

The nurse is caring for a 9-month-old child after cleft palate repair. Elbow restraints (security devices) have been applied. The mother visits the child and asks the nurse to remove the restraints. Which action should the nurse take to both assure the child's safety and the mother's concern?

Remove a restraint from one arm while the mother is present.

The nurse instructs a client on how to use crutches safely for ambulating at home. Which instruction should the nurse recommend to best minimize the risk of falls?

Remove all area rugs.

A client is receiving intravenous (IV) antibiotic therapy at home via an intermittent IV catheter. In order to facilitate the early detection of IV therapy complications, which intervention should be included in the client's education?

Report local pain, drainage, or edema.

The nurse manager is providing an educational session to the nursing staff on the safe use of physical restraints. Which are examples of safety guidelines when using physical restraints? Select all that apply.

Restraints should be secured with a quick-release tie. A primary health care provider's prescription is required. Restraints are used when other measures have failed to prevent self-injury or injury to others.

The nurse is creating a plan of care for a client receiving enteral feedings. The nurse identifies which concern as the highest priority for this client?

Risk of aspiration

The nurse in a day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and plans activities that will meet the child's needs. Which activity should be the priority for a child with autism?

Safety with activities

The nurse is caring for a client diagnosed with both fine hand tremors and glaucoma. The client reports difficulty instilling prescribed once-in-the-morning glaucoma eye drops because of shaking hands. Which instruction should the nurse provide to the client to best alleviate this problem?

Schedule a home care medication tech to instill the eye drops every morning.

The nurse hangs a 1000-mL bag of intravenous (IV) fluid for an assigned client. Forty-five minutes later, the nurse notes that the client is reporting a pounding headache, dyspnea, and apprehension. An assessment confirms an increased pulse rate. The IV bag has 500 mL remaining. Which action should the nurse take first?

Shut off the IV infusion.

The nurse has been asked to do a safety assessment in the home of a family who have 2-year-old twins. The nurse should determine that which assessment data is the highest priority safety hazard to the children?

Small toys with loose parts are in the playpen.

An adolescent tells the nurse at the clinic that using rollerblades outside during the summer months is a new hobby and that protective equipment is not being worn. The nurse determines that this adolescent is at risk for which trauma-associated condition?

Spinal cord injury

The nurse is caring for a client who has a prescription for wrist restraints. Which priority measure should the nurse implement while providing safe care for this client?

The call light is within the client's reach.

The home care nurse has been called to the home of an older postoperative cardiovascular client. The caregiver tells the nurse, "The client has fallen out of bed 3 times." Which observation by the nurse would indicate the need for further teaching for the caregiver to ensure safety?

The caregiver leaves side rails down while the client is in bed.

The nurse provides instructions to a client about the use of a cane and watches as the client uses the device. Which observation should indicate to the nurse there is a need for further teaching?

The client moves the cane and the stronger leg forward first, then moves the weaker leg forward.

The home care nurse conducting an admission assessment on a client observes the client ambulate with the use of a cane. The nurse should intervene and determine that there is a need for further teaching if the nurse observes which action?

The client moves the cane and the unaffected side together.

When assessing the client with a wrist restraint at the beginning of the day shift, which observation by the charge nurse should indicate that the nurse who placed the restraint on the client failed to follow safety guidelines?

The wrist restraint was applied snugly.

The nurse has been asked to do a safety survey at a children's day-care center. All of the children cared for at the center are 1 to 3 years old. The nurse should determine that which safety hazard is the most hazardous to the toddlers at the center?

Toys with small, loose parts in the playroom

A client with a new diagnosis of migraine headaches has a history of diagnosed hypotension. The nurse predicts that the client will most likely experience undesirable cardiac side effects if the primary health care provider prescribes which medications? Select all that apply.

Verapamil or Propranolol