Chap 27 safety prep u

RACE

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.

ABCs

airway, breathing, circulation

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out a bonfire, what will the nurse identify?

Class A fire extinguishers contain water under pressure and are used for burning paper, wood, and cloth. Other answers are incorrect.

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out an electrical fire, what will the nurse identify?

Class C fire extinguishers contain dry chemicals and are used to extinguish electrical fires. Other answers are incorrect.

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?

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 new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant?

Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should remain in a rear-facing safety seat.

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of:

Mass trauma terrorism is caused by bombs and other explosives that are used to inflict mass trauma and cause multiple fatalities. Bioterrorism involves the deliberate spread of pathogenic organisms into the community. Chemical terrorism involves the deliberate release of a chemical compound for the purpose of causing mass destruction. Nuclear terrorism involves the dispersal of radioactive materials into the environment for the purpose of causing injury and death.

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?

Teamwork and collaboration is one of the core QSEN competencies, and is exemplified by increasing communication between different disciplines. The six QSEN competencies do not explicitly address financial costs of care, higher levels of education for nurses, or increased partnership between hospitals and educational institutions.

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

The extremity restraint is appropriate during an accidental removal of therapeutic devices, because it provides short-term restraint designed to control all movement.

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

The extremity restraint is appropriate during an accidental removal of therapeutic devices, because it provides short-term restraint designed to control all movement. The vest restraint, mummy restraint, and elbow restraint are not appropriate in this situation.

airway, breathing, and circulation level of consciousness and orientation intravenous access and IV fluids wounds and tubes items within the client's reach

The nurse is performing an assessment following a surgical procedure. The most important assessment is the client's airway, breathing, and circulation. A problem with any of these would indicate a situation requiring immediate action. The nurse would then assess the client's level of consciousness and orientation. Again, an abnormality in these areas could indicate the need for immediate action. Next, the nurse checks the IV site and fluids infusing for patency, solution, and rate. Then the nurse would assess the client for wounds and the tubes for presence, patency, and fluid color and amount. The paramount concern is for the client. After client assessments are completed, then the nurse checks for the call bell, water if allowed, and other personal items within reach of the client.

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states:

The nurse should determine that additional information is needed when the participant states that the chin strap should fit two fingers underneath the chin. The chin strap needs to be snug, and the ability to fit two fingers between the strap and the chin indicates it is not snug enough. The helmet should rest 1 in (2.5 cm) above the eyebrows. Children should wear a helmet every time they ride a bike or are strapped into a bike seat as a passenger.

The nurse working on a medical surgical floor should determine that which clients are at risk for a fall? Select all that apply.

The nurse should determine that the following clients are fall risks: client taking a diuretic, client with advanced Alzheimer disease, and the client with macular degeneration. These clients exhibit risk factors for a fall, including decreased vision (macular degeneration), confusion/disorientation (advanced Alzheimer disease), and urgency from taking a diuretic. Being hard of hearing will not place a client at risk for a fall. A slightly elevated blood pressure such as 142/90 will not place a client at risk for a fall.

The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply.

An order for restraints from the licensed health care provider must be obtained within minutes after the restraint is applied. Frequent and regular nursing assessments are required of the restrained client's vital signs; circulation; skin condition or signs of injury; psychological status and comfort; and readiness for discontinuing the restraint. The nurse must explain the need for restraints with the family. When the assessment findings indicate that the client has improved, restraints must be removed.

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?

Asking multiple levels of questions is essential to the process of root cause analysis and can be helpful in revealing underlying causes. Understanding how the behavior of the two nurses involved in aspects of care that contributed to the error is critical in this scenario. This opens avenues for future corrective actions to reduce the chance of repeating such an error. Each of the other listed questions addresses a valid aspect of the event, but none address the underlying causes, which is the focus of root cause analysis.

A nurse is applying restraints to a confused client who has threatened the safety of a roommate. Which actions would the nurse perform when properly applying restraints to a client? Select all that apply.

Bony prominences should be padded to protect skin integrity. The restraint should be removed so the extremity can be moved through range-of-motion and to ensure that circulation is not impaired. The least restrictive type of restraint should be chosen. A finger should be able to fit between the restraint and the body part to ensure the restraint is not too tight. The restraint should be fastened to non-moving parts of the bed. Fastening a restraint to a side rail may cause the restraint to tighten or injure the body part when the rail is lowered or raised.

A nurse is administering a scheduled medication to a client using the institution's bar code system. The nurse has scanned the client's armband as well as the scheduled medication. The system has signaled a discrepancy between the dose prescribed and the dose scanned. What is the nurse's most appropriate response?

If an error message is received during medication administration, the nurse must be diligent in determining the reason for the message and correcting whatever is causing the error. It is not possible to say what the appropriate response would be until the nature of the discrepancy is identified. It would be prudent to enlist the help of a colleague to ensure the right decision is made. Administering the medication without clarification is as potentially unsafe as placing the medication on hold until the next scheduled dose.

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

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.

6 QSEN competencies

Patient-centered care. Evidence-based practice. Teamwork and collaboration. Safety. Quality improvement. Informatics.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

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 nurse is providing care for a client whose blood pressure has been gradually dropping over the course of a shift. The nurse has decided to inform the client's primary care provider by telephone using the SBAR tool. The nurse will end this communication by:

SBAR -- Situation, Background, Assessment, Recommendation - is a technique frequently used in healthcare settings that can be used to facilitate prompt and appropriate communication. In the SBAR tool, the "R" denotes a recommendation, not a review. Assessment results are shared earlier. The desired outcomes are not necessarily part of the recommendation.

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.

Some of those factors include the client's developmental level, lifestyle, mobility, sensory perception, knowledge level, communication ability, physical health state, and psychosocial state. The community's population and the type of facility that the client is in should not impact the safety of the client.

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

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.

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention?

The priority is to apply an allergy-alert bracelet to the client so that any member of the interdisciplinary team can quickly identify the latex allergy. All other actions can take place immediately thereafter.

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

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.

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?

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.

Root Cause Analysis (RCA)

determines underlying cause of adverse events; used after incident to uncover primary cause