Safety Questions

A nurse uses the get up and go test to assess the client for weakness, poor balance, and decreased flexibility. Place the following actions in order in which they should be implemented when employing the get up and go test. 1. Ask the client to walk 10 feet and then return to the chair. 2. Ask the client to close their eyes. 3. Ask the client to open their eyes. 4. Ask the client to sit in a chair. 5. Ask the client to stand.

4,5,2,3,1

A client brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. Which rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug? A. Controls stray electrical currents B. Promotes efficient use of electricity C. Shuts off the appliance if there is an electrical surge D. Divides the electricity among the appliances in the room

A

A home care nurse is assigned to care for an older adult living at home. Which is the first action the home care nurse should employee to prevent falls by this older adult? A. Conduct a comprehensive risk assessment B. Encourage the client to remove throw rugs in the home C. Suggest installation of adequate lighting throughout the house D. Discuss with the client the expected changes of aging that place one at risk

A

A nurse is orienting a new admitted client to the hospital. Which is the most important for the nurse to teach the client how to do? A. Notify the nurse when help is needed B. Get out of the bed to use the bathroom C. Raise and lower the head and foot of the bed D. Use the telephone system to call family members

A

A nurse is preparing it quiet for a physical examination. Which is the most important for the nurse to do in this situation? A. Identify the positions contraindicated for the client during the examination B. Explored the clients attitude toward healthcare providers C.Inquire about other professionals caring for the client D. Ask when the client last had a physical examination

A

A primary health-care provider prescribes a vest restraint for a client. Which should the nurse do first when applying the restraint? A. Perform an inspection of the client's skin where the restraint is to be placed B. Ensure that the back of the vest is positioned on the client's back C. Permit four fingers t slider between the client and the restraint D. Secure the restraint to the bed frame using a slipknot

A

A toaster is on fire in the pantry of a hospital unit. Which should the nurse do first? A. Activate the fire alarm B. Unplug the toaster from the wall C. Put out the fire with an extinguisher D. Evacuate the clients from the room next to the kitchen

A

Which nursing intervention enhances an older adult's sensory perception and thereby helps prevent injury and walking from the bed to the bathroom? A. Providing adequate lightning B. Raising the pitch of the voice C. Holding onto the client's arm D. Removing environmental hazards

A

Which is inappropriately worded goal for a client who is at risk for falling? (SATA) A. "The client will be able to walk from the bed to a chair safely while hospitalized" B. " The client will be taught how to call for help to ambulate" C. " The client will be kept on bed rest when dizzy" D. "The client will be restrained when agitated" E. "The client will be free from trauma"

A,E

A nurse identifies the presence of smoking exiting the door to the dirty utility room. Please the nurses actions in order of priority using the RACE model. 1. Pull the fire alarm 2. Close unit doors and windows 3. Shut the door to the utility room 4. Provide emotional support to agitated clients

1,3,2,4

Which clinical manifestation indicates that further nursing assessment is necessary to determine if the client is having difficulty swallowing? (SATA) A. Debris in the buccal cavity B. Coughing episodes C. Noisy breathing D. Slurred speech Drooling

ALL

A male client is admitted to the ambulatory care for a bilateral herniorrhaphy. A nurse on the unit interviews the client, obtain the clients vital's signs, and reviews the primary healthcare providers prescriptions. What should the nurse do first? A. Contact the operating suite and inform them of the clients latex allergy B. Ensure the clients allergy ban includes the client identified allergies C. Notify the primary healthcare provider of the clients elevated vital signs D. Share the information about the clients anxiety with health team members

B

A nurse is caring for a client with Parkinson's disease who is experiencing difficulty swallowing. For which major potential problem associated with dysphasia should the nurse assess the client? A. Anorexia B. Aspiration C. Self-care deficit D. Inadequate intake

B

A nurse is caring for a client with a nasogastric tube for gastric decompression. Which nursing action takes priority? A. Discontinuing the wall suction when providing nursing care B. Positioning the client in the semi-Fowler's position C. Instilling the tube with 30 mL of air every 2 hours D. Caring for the nares at least every 8 hours

B

A nurse is preparing a bed to receive a newly admitted client to the hospital. Which action is most important? A. Placing the clients name on the end of the bed B. Ensuring that the bed wheels are locked C. Positioning the call bell in reach D. Raising one side rail

B

A school nurse is teaching children about fire safety procedures. Which is the first thing they should be taught to do if their clothes catch on fire? A. Yell for help B. Roll on the ground C. Take their clothes off D. Pour water on their clothes

B

An unconscious client begins vomiting. In which position should the nurse place the client? A. Supine B. Side-lying C. Orthopneic D. Low-Fowler

B

Which is the priority nursing intervention to prevent client problems associated with latex allergies? A. Use non latex gloves B. Identify persons at risk C. Keep a latex-free supply cart available D. Administer an antihistamine prophylactically

B

Which intervention should the nurse implement when assisting a client to use a bedpan? (SATA) A. Ensure that the bedrails are raised after the client is on the bedpan B. Position the rounded rim of the bedpan under the clients buttocks C. Encourage the client to help as much as possible when using the bedpan D. Raise the head of the bed to a semi Fowler position once the client is placed on the bedpan E. Dust talcum powder on the rim of the bedpan before placing the bedpan under the client

B,C,D

An adult client consistently tries to pull out a nasogastric tube. As a last resort to maintain integrity of the tube in client safety, the nurse obtained a prescription for hours straight. Which type of a straight is appropriate in this situation? (SATA) A. Mummy restraint B. Elbow restraint C. Jacket restraint D. Wrist restraint E. Mitt restraint

B,D,E

Which human response to illness alerts the nurse that a client is at risk for aspiration during meals? (SATA) A. Bulimia B. Lethargy (sleepy) C. Anorexia D. Stomatitis (inflammation of mucous membranes) E. Dysphasia

B,D,E

A nurse is planning care for a client who requires bilateral armor straight because the client is delirious and attempting to pull out a urinary retention catheter. Which information is important to consider when planning care for this client? (SATA) A. Use of restraints adequately prevents injury B. Reasons for use of restraints must be clearly documented C. Most clients recognize that restraints contribute to their safety D. Restraints need a health-care provider's prescription before application E. Laws permit the use of restraints when specific guidelines are followed

B,E

A nurse is assessing a client who is being admitted to the hospital. Which is the most important info that indicates whether the client is at risk for physical injury? A. Weakness experienced during a prior admission B. Medication that increases intestinal motility C. Two recent falls that occurred at home D. The need for corrective eyelashes

C

A nurse is planning care for a client with a wrist restraints. How often should they were straight be removed, the area massaged, and the joints moved through their full range? A. Once a shift B. Once an hour C. Every 2 hours D. Every 4 hours

C

A three-year-old child is admitted to the pediatric unit. Which should the nurse do to maintain the safety of this preschool age child? A. Teach the child how do use the call bell B. Put the child in a crib with high side rails C. Ensure the child is under continuous supervision D. Have the child stay in the playroom most of the day

C

Profuse smoking is coming out of the heating unit in the clients room. Which of the nurse do first? A. Open the window B. Activate the fire alarm C. Move the client out of the room D. Close the door to the client's room

C

The risk management coordinator is preparing a program on the factors that contribute to falls in a hospital setting. Which factor that most often contributes to falls should be included in this program? A. Wet floors B. Frequent seizures C. Advanced age of clients D. Misuse of equipment by nurses

C

Which is the last step in making an occupied bed that the nurse should teach a nursing assistant? A. Elevating the head of the bed to a semi-Fowler's position B. Ensuring that the client is in a comfortable position C. Lowering the height of the bed toward the floor D. Raising both the upper side rails on the bed

C

Which should the nurse do too best prevent a client from falling? A. Provide a cane B. Keep walkways clear of obstacles C. Assist the client with ambulation D. Encourage the client to use hallway handrails

C

A client has dysphasia. Which nursing action takes priority when feeding this client? A. Ensuring that dentures are in place B. Medicating for pain before providing meals C. Providing verbal cueing to swallow each bite D. Checking the mouth for emptying between every bite

D

A family member brings an electric radio to a client in a long-term care facility. The client tells the nurse that an electrical shock was felt while turning on the radio. Which should the nurse do first? A. Arrange for the maintenance department to examine the radio B. Disconnect the radio from the source of energy C. Check the client's skin for electrical burns D. Take the patient's apical pulse

D

A nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized client should they be taught is at the highest risk for injury? A. School-age child B. Comatose teen C. Post menopausal women D. Confused middle-age man

D

A nurse in the nursing education department of a community hospital is planning an in-service education class about injury prevention. Which factor that most commonly causes basically injuries in the hospitalized clients should be included in the teaching plan? A. Malfunctioning equipment B. Failure to use restraints C. Visitors D. Falls

D

A nurse is caring for a client with dementia. Which time of the day is the most concerned for the nurse when trying to protect this client from injury? A. Afternoon B. Morning C. Evening D. Night

D

A nurse is caring for a confused client. Which should the nurse do to prevent this client from falling? A. Encourage the client to use the corridor handrails B. Place the client in a room near the nurses' station C. Reinforce how to use the call bell D. Maintain close supervision

D

A nurse must apply a hospital gown that does not have snaps on the shoulders to a client receiving an IV infusion in the forearm. Which should the nurse to? A. Put the gout on the clients arm without the IV, drape the gown over the other shoulder, and adjust the closure behind the neck B. Close the clamp on the IV tubing for no more than 15 seconds while putting the gown on the client C. Disconnect the clients IV at the insertion site, apply the gown, and then reconnect the IV D. Insert the client's IV bag and tubing through the sleeve from inside the gown first

D

Which action is important when the nurse uses a stretcher? (SATA) A. Raising the bed above the level of stretcher when transferring a client from the stretcher to a bed B. Guiding the stretcher around the turn by leading with the end of the clients head C. Ensuring that the clients head is at the end of the swivel wheels D. Pulling the stretcher on the elevator with the clients feet first E. Pushing the stretcher from the end with the clients head

E