Chapter 25 Safety
A patient has accidentally consumed kerosene. Which nursing intervention complicates the patient's condition further? a. Inducing vomiting b. Maintaining the airway c. Administering oxygen d. Measuring oxygen saturation
a
When teaching a patient about fire safety, which activity does the nurse know is the leading cause of fire-related death? a. Cooking b. Playing with matches c. Smoking d. Heating with kerosene heaters
1. Answer: a.
The nurse is performing a fall risk assessment on a newly admitted patient. Which finding is a greater known risk factor for falls? a. Taking aspirin b. Urinary incontinence c. Multiple comorbidities d. Malnutrition
1. Answer: b
Which restraint-free alternative is best for the nurse to use for an 84-year-old patient after hip replacement who has confusion and incontinence? a. A room near the nurses' station and decreased sensory stimuli b. A pressure sensor alarm and a room near the nurses' station c. Side rails up and decreased sensory stimuli d. A 24-hour sitter and the patient's favorite TV program
1. Answer: b
Which measures can the nurse teach to prevent poisoning of children? (Select all that apply.) a. Install safety latches on reachable cabinets. b. Keep syrup of ipecac on hand. c. Use childproof caps on medications. d. Use a plunger rather than a chemical drain cleaner. e. Keep cleaning supplies under the kitchen sink.
1. Answers: a, c, d
What other health care professional should the nurse consult first when a patient has difficulty with activities of daily living (ADLs) such as bathing and dressing and why? a. Occupational therapist to evaluate the ability to perform ADLs b. Physical therapist to evaluate the patient's need for assistive devices c. Social worker to arrange for needed assistive devices d. Area agency on aging to arrange for Meals on Wheels
Answer: a
An elderly client residing in the community with cardiopulmonary compromise and impaired ability to perform activities of daily living (ADLs) presents safety concerns to the nurse. Which is the greatest concern? a. Ability to obtain and take medications correctly b. Ability to safely get on and off a toilet c. Ability to safely procure food and prepare meals d. Ability to safely eat without choking
Answer: b
The nurse is aware that parents are being safety advocates when they do which of the following? a. Keep a rear-facing car seat until the child is at least 12 months old. b. Limits the amount of TV and video viewing of school age children to 3 to 4 hours per day. c. Asks the teenager to turn the headphone volume down when the music is audible to others. d. Avoid painting in a house unless the temperature is above 60 degrees Fahrenheit.
Answer: c
Which activity would be most appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for fall risk and complications of restraint use b. Evaluating the patient's ability to perform activities of daily living (ADLs) c. Assisting with or performing the patient's ADLs d. Teaching the patient use of assistive devices
Answer: c
Which activity would be most appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for fall risk and complications of restraint use b. Evaluating the patient's ability to perform activities of daily living (ADLs) c. Assisting with or performing the patient's ADLs d. Teaching the patient use of assistive devices
Answer: d
When working with radiation diagnostics or treatments, which preventive measures should be followed to avoid exposure? (Select all that apply.) a. Using lead shielding of patients and staff b. Keeping staff at the farthest distance possible from the radiation source c. Limiting the length of exposure d. Wearing a badge to monitor the length of exposure e. Following procedures and safety checks
Answers: a, b, c, d, e
The nurse is teaching a group of parents about strategies to minimize lead exposure in children. Which statement made by a parent indicates the need for further teaching? a. "I will arrange yearly checks for the heaters that we use." b. "I will use a filter for all sources of water in our home." c. "I will wash and peel vegetables before eating them." d. "I will teach my children to frequently wash their hands."
a
Which fall risk assessment tool would the nurse employ for the patient using a walker? a. Morse Falls Scale b. Hendrich II Fall Risk Model c. New York-Presbyterian Fall and Injury Risk Tool d. Johns Hopkins Hospital Fall Assessment Tool
a
A nurse is using physical restraints for a patient in the medical surgical unit. For which possible reasons would the nurse use restraints on the patient? Select all that apply. a. Confused and disoriented b. Trying to remove medical devices c. Verbally aggressive to the nurse d. Sedated and needs to be protected from falling out of bed e. Being prepared for a routine physical assessment
a, b
A patient sustained minor burns in a fire at home. After stabilizing the patient, the nurse asks the patient to obtain a fire extinguisher at home. Which instructions does the nurse provide to the patient? Select all that apply. a. "Make it inaccessible to the children." b. "Place it on each level near an exit." c. "Keep it at a low level (height) in the room." d. "Place it in clear view." e. "Keep it away from stoves and heating appliances."
a, b, d, e
Which instructions would the nurse give to the parents of toddlers regarding medication safety? Select all that apply. a. "Use child locks for medication cabinets." b. "Place childproof caps on all of the bottles." c. "Put the medications in different bottles." d. "Keep all the medications in the freezer." e. "Keep the medications on a high shelf."
a, b, f
A patient has recovered from seizures in a postoperative ward. Which action by the nurse would ensure continued safety of the patient? Select all that apply. a. The side rails of the bed should be raised. b. The patient should be placed in the supine position. c. The call light and intercom should be kept near the patient. The use of pillows should be avoided. d. The bed should be placed in the highest position
a, c
Of which common causes of death in the elderly population would a nurse working in a nursing home be aware? Select all that apply. a. Falls b. Poisoning c. Hypothermia d. Heat stroke e. Motor vehicle accident
a, c, d
The nurse is teaching a group of new mothers about interventions to promote infant safety. Which instructions would the nurse include in her teaching? Select all that apply. a. Lay the infant to sleep on the back. b. Fill the crib with pillows and large stuffed toys. c. Check with the U.S. Consumer Product Safety Commission for information on approved cribs, devices, and toys. d. Do not leave the infant unattended in a tub. e. Attach pacifiers to a string and place it around the infant's neck
a, c, d
Which factors would the nurse assess using the Johns Hopkins Hospital Fall Assessment Tool? Select all that apply. a. History of falls b. Dizziness or vertigo c. Specific medications d. Secondary diagnosis e. Patient care equipment
a, c, e
A patient has been involved in a fire accident and wishes to use a fire extinguisher for future protection. Which information does the nurse share with the patient about using a fire extinguisher? a. The type of extinguisher used is not specific to the type of fire. b. The fire extinguisher should be used only when a fire is confined to small areas. c. The occupants should be sent out of the house once the fire extinguisher is used. d. Fire department personnel should be called only when none of the attempts to put out the fire are successful.
b
Which topic would the nurse include in a group discussion with parents regarding safety measures to prevent injuries in teenagers? a. Choking hazards b. Motor vehicle accidents c. Occupational hazards d. Physiologic changes
b
A nurse is caring for an older adult in his home and is concerned about his infection control and his risk of injury. Which activities should the nurse perform to assess this patient's risk of injury? Select all that apply. a. Inspect the patient's food. b. Perform a home hazard appraisal. c. Inquire about the patient's visual acuity. d. Observe the patient's posture and balance. e. Assess the patient's gastrointestinal system.
b, c, d
An agitated patient has been physically restrained for 2 hours. Which interventions would the nurse include in the plan of care as alternatives to using restraints? Select all that apply. a. Take the patient to a brightly lit room. b. Include the use of aromatherapy. c. Use gentle massage for relaxation. d. Let the patient listen to music. e. Keep the patient in isolation.
b, c, d
Which guidelines would the nurse working in the x-ray unit of a hospital follow with respect to the patient's safety? Select all that apply. a. Counsel the patient that radiation is not harmful. b. Ask the patient to wear lead aprons when in the radiation zone. c. Limit the patient's time spent near the source of radiation. d. Make the distance from the source as maximum as possible. e. Allow the patient to freely move in the radiation zone as desired
b, c, d
Which factors would the nurse evaluate using the Hendrich II Fall Risk Model? Select all that apply. a. History of falls b. Get-Up-and-Go test c. Presence of intravenous lines d. Use of benzodiazepines e. Use of ambulatory aids
b, d
Which measure would ensure normal breathing and reduced risk of musculoskeletal injury to a patient having seizures? Select all that apply. a. Tighten the waist belt. b. Loosen the collar. c. Restrain the patient. d. Turn the patient's head to the side. e. Place a soft pillow under head.
b, d
A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which instruction would the nurse give to this parent? a. "Give the child milk." b. "Give the child syrup of ipecac." c. "Call the poison control center." d. "Take the child to the emergency department."
c
Which group has the highest risk of death due to suffocation caused by choking on foreign objects? a. Adults b. Infants c. Toddlers d. Older adults
c
Which intervention would the nurse perform before applying restraints? a. Position the patient in the proper body alignment. b. Inspect the area where the restraint will be placed. c. Assess whether the patient actually needs a restraint. d. Review the company's directions before applying.
c
A patient suffers a cerebrovascular accident. On assessment, the nurse learns that gait and vision are normal, but the patient is anxious and has a fear of falling. How should the nurse help the patient in managing anxiety? Select all that apply. a. Refer the patient for an ophthalmologic assessment. b. Suggest the elimination of obstacles in the home. c. Establish a therapeutic relationship with the patient. d. Encourage the use of effective coping skills. e. Remind the patient to scan the surrounding environment.
c, d
The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. Which action would be appropriate for the nurse to take in this situation? Select all that apply. a. Contact the nursing supervisor. b. Restrict the family's visiting privileges. c. Inform the family of the risks associated with side-rail use. d. Discuss alternatives with the family that are appropriate for this patient. e. Thank the family for being conscientious and put the four rails up. f. Ask the family to stay with the patient if possible.
c, d, f
A patient with epilepsy has a seizure. In which position would the nurse place the patient? a. Sitting b. Prone c. Supine d. Side-lying
d
A patient who was using a charcoal grill inside the garage presents to the emergency room with dizziness, drowsiness, and nausea. These assessment findings would be consistent with which type of poisoning? a. Lead poisoning b. Antifreeze poisoning c. Ammonia poisoning d. Carbon monoxide poisoning
d
The nursing assessment of a 78-year-old woman reveals shuffling gait, decreased balance, and instability. Which nursing diagnosis is best supported by these findings? a. Activity intolerance (ICNP) b. Impaired mobility in bed (ICNP) c. Arthritis pain (ICNP) d. Risk for fall (ICNP)
d
There is a fire in a hospital. Which action is the first priority action of the nurse? a. Activating the fire alarms b. Confining the fire c. Extinguishing the fire d. Rescuing patients in immediate danger
d
Which action taken by the new nurse who is caring for a patient experiencing a seizure requires correction? a. Continuing to monitor the patient's status throughout the seizure b. Placing the patient's head on a soft pillow c. Turning the patient to a side-lying position d. Restraining the patient with his or her hands
d
Which topic would the nurse discuss with senior citizens about the leading cause of injury in older adults? a. Drowning b. Illicit drug use c. Work-related hazards d. Complications from falls
d
Which environmental factor would the nurse consider while assessing the risk of falls in an elderly patient? a. Daily salt intake b. Regular exercises c. Cognitive status d. Proper illumination
d.
A patient who is scheduled for radiation therapy says to the nurse, "I'm scared. Would you please stay with me during the therapy?" Which response by the nurse would be appropriate? a. "Feel free to ask any friends or family to stay beside you during the therapy." b. "Don't worry, I'll stay right beside you and hold your hand during the therapy." c. "I'll ask the health care provider to postpone the radiation treatment." d. "I cannot get too close to the radiation, but I will be as close as possible."
d. "I cannot get too close to the radiation, but I will be as close as possible."
