Chapter 25: Safety
Which factors would the nurse evaluate using the Johns Hopkins Hospital Fall Assessment Tool?
History of falls, influence of age, advanced age, mobility, patient care equipment, specific medication, and cognitive and elimination functions.
Which factors would the nurse evaluate using the Morse Falls Scale?
History of falls, presence of secondary diagnosis, presence of IV or saline lock, use of ambulatory aid, gait and mental status
Which factors would the nurse evaluate using the New York-Presbyterian Fall and Injury Risk Tool?
Fall history, gender, mental status, gait, and use of sedatives
Which factors would the nurse evaluate using the Hendrich II Fall Risk Model?
Impulsivity, symptomatic depression, altered elimination, male gender, Get-up-and-Go test, use of benzodiazepines, use of antiepileptics, and dizziness or vertigo
TRUE/FALSE When preparing equipment for a patient transfer from bed to chair, position a wheelchair or supportive chair at a 45-degree angle close to bed.
TRUE
The nurse has applied extremity restraints on a patient. What should the nurse assess on a regular basis? (Select all that apply) a. Skin integrity and range of motion b. Readiness for discontinuation of restraint c. Pulse and temperature of restrained body part d. The IV catheter remains interrupted e. Present of visitors at patient's bedside f. Ability of patient to breathe without restriction
a, b, c, 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
a, b, c, d, e
You are going to evaluate a patient who has required assistance with feeding. Which of the following are examples of appropriate evaluation measures? (Select all that apply.) a. Monitor weight. b. Inspect the mouth for food pocketing. c. Observe the intake of all meals served. d. Ask the patient in what order he wishes to eat foods. e. Monitor patient's pulse oximetry while patient is eating.
a, b, c, e
A patient is admitted to a medical unit with pneumonia. She is able to ambulate on her own to the bathroom. What safety precautions should be taken for this patient? (select all that apply) a. ensure the pathway to the bathroom is clear b. keep the bed in the low locked position c. keep patient's personal items on the overbed table d. place a bedside commode near bead with back to wall e. keep all side rails up when patient is in bed f. explain use of the call light
a, b, c, f
A nursing instructor asks what may cause orthostatic hypotension. The nursing student correctly replies: (Select all that apply.) a. prolonged bed rest b. antihypertensives c. low body weight d. hypovolemia e. room temperature
a, b, d
An elderly patient was recently admitted to a medical unit with severe fluid and electrolyte imbalance. His family states that he has periods of confusion. What are some practical precautions the nurse can take to ensure the patient's safety without having to use restraints? (select all that apply) a. perform nurse toilet and turn or comfort and safety rounds hourly b. activate the bed alarm when the patient is in bed c. administer iv fluids to reverse fluid imbalance d. make staff assignments for patients in adjacent rooms e. use a security camera to monitor the patient while in bed
a, b, d
Which of the following are appropriate safety measures for the use of a wheelchair? (select all that apply.) a. brakes on both wheels are locked when the patient is being transferred into the wheelchair b. back the wheelchair into and out of an elevator c. brakes on the side nearest the bed are locked when the patient is being transferred into the wheelchair d. seat patient in wheelchair with buttocks against back of seat e. keep footplates lowered for transfer into the wheelchair
a, b, d
In the change of shift report, the nurse was told a patient requires "minimal assistance with meals." What should the nurse expect to do for the patient at mealtime? (Select all that apply.) a. Open packages and cartons. b. Document the intake. c. Place the meal tray in the room, leave the room, and return in 30 minutes to remove the tray. d. Ask the patient if he or she needs the nurse to cut up the food or butter the bread. e. Assist the patient to an upright position. f. Feed the patient.
a, b, d, e
A patient has been recently admitted to the hospital. What indications, if observed, may suggest that the patient has dysphagia (difficulty swallowing)? (Select all that apply.) a. Change in voice after swallowing. b. Wet, gurgly voice. c. Drowsiness. d. Loss of appetite e. Persistent drooling.
a, b, e
Which of the following can be delegated? (Select all that apply.) a. Transfer from bed to chair. b. Completing a fall risk assessment tool. c. Applying restraints. d. Moving a patient with an acute spinal cord injury up in bed. e. Determining a dependent patient's risk for aspiration.
a, c
A patient puts on her call light and requests to get up in a chair. The nurse who responds to the call light is unfamiliar with the patient's capabilities. To ensure a safe transfer, what should the nurse assess before assisting the patient to the chair? (Select all that apply.) a. whether the patient has a walker or any other assistive device b. why the patient wants to get up in a chair c. if the patient has any noticeable muscle weakness or neurological impairment d. how many people usually assist the patient when transferring to a chair e. ensure the patient has socks on her feet before getting up
a, c, d
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
a, c, d
The daughter of an elderly patient comes to visit her mother, who was recently admitted to the hospital. The daughter notices a yellow band on her mother's wrist and asks what it is for. The nurse correctly responds that it is used to identify patients who are at risk for falling and provides additional information as to what makes a patient a fall risk. What information should the nurse include? (Select all that apply.) a. Age over 65. b. Continent of urine and bowel. c. Taking muscle relaxants. d. New and different environment. e. History of a fall. f. Having an IV.
a, c, d, e, f
The nurse checks the patient's extremity restraints hourly. What is the nurse looking for specific to this type of restraint? (Select all that apply.) a. Distal pulses. b. Whether the patient wants the restraints released. c. Temperature of the skin distal to the restraint. d. Sensation of the distal part of the extremity. e. The character of respirations. f. The patient's blood pressure. g. Proper placement of the restraint. h. Color of skin distal to the restraint.
a, c, d, g, h
The nurse is encouraging the patient to get out of bed and sit up in a chair. Which of the following are accurate statements regarding the benefits for getting up in the chair? (Select all that apply.) a. a gradual increase in time out of bed will increase your tolerance and endurance b. moving quickly from the bed to the chair will help reduce dizziness over time c. repeated transfers will increase your endurance and help you gain independence d. pain is a good indicating you are gaining muscle strength and joint mobility e. getting up will help your breathing and circulation and may make you feel better
a, c, e
What are some examples of "verbal coaching" that can be used when feeding the adult dependent patient who has difficulty swallowing? (Select all that apply.) a. "Raise your tongue to the roof of your mouth." b. "Let's turn on the television and see what's cooking on the Food Network." c. "Close your mouth and swallow." d. "Green beans are very nutritious." e. "Open your mouth."
a, c, e
You need to move a patient up in bed. What assessment measures should you make before performing this procedure? (select all that apply) a. the patients ability to help with the procedure b. the patients weight c. the patients muscle strength d. what medications the patient has been taking e. the presence of tubes, incisions, and equipment
a, c, e
The nurse walking down the hospital corridor glances into the patient's room and sees the patient's feet and legs sticking out from the bathroom entrance. The nurse immediately goes into room and determines that the patient has fallen. What actions should be taken? (select all that apply) a. fill out an agency occurrence or sentinel event report b. avoid moving the patient until the health care provider arrives c. call for assistance d. apply a restraint after returning the patient to bed e. assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.). f. asses for injury g. notify the health care provider
a, c, e, f, g
The nurse is planning tasks for the day. Which of the following patients would require repositioning at this time? (Select all that apply.) a. A comfortable patient with paraplegia who has been sitting in a chair for 30 minutes. b. A patient who has been sitting in a chair for 10 minutes watching television. c. A patient who was repositioned for comfort 30 minutes ago after being moved up in bed. d. A patient in correct body alignment who was turned 2 hours ago.
a, d
Who may require temporary restraints? (select all that apply) a. a patient who is at risk for falls when nonrestrictive measures have failed b. a patient who walks in his o her sleep c. a patient who is uncooperative d. a confused patient who may interrupt prescribed therapy, such as nasogastric tube. e. a patient who may be a risk to self or others
a, d, e
Which of the following actions can be taken to assist the patient with dysphagia to swallow and to prevent aspiration? (Select all that apply.) a. Position patient upright with chin-tuck position b. Position the patient upright in a bed or chair with the head slightly extended backward c. Place half to 1 teaspoon of food on the affected side of the mouth. d. Place half to 1 teaspoon of food on unaffected side of the mouth. e. Provide verbal coaching while feeding the patient. f. Allow time for adequate chewing and swallowing. g. Provide mouth care after meals. h. Serve patient pureed foods, as ordered.
a, d, e, f, g, h
The nurse is delegating the feeding of dependent patients. Under which circumstance should the nurse attend to the patient, rather than the NAP? a. A 76-year-old who was just admitted to the unit after having a CVA (stroke). b. A 43-year-old who is blind. c. A 26-year-old who has suffered a fracture of both arms. d. A 54-year-old who has multiple sclerosis, but is able to eat with assistance.
a. A 76-year-old who was just admitted to the unit after having a CVA (stroke).
A patient with left-sided weakness needs to be transferred to a wheelchair. On which side of the bed should the nurse place the wheelchair? a. On the patient's strong (unaffected) side. b. On the patient's weak (affected) side. c. Whichever side the patient prefers. d. Either side of the bed.
a. On the patient's strong (unaffected) side
The nurse manager is reviewing the use of restraints during an in-service with the staff. Which of the following is inaccurate information that should not be included in the discussion? a. Restraints provide a reliable method to prevent falls without serious complications. b. Attach the restraint to the movable part of the bed frame. c. When all side rails are raised, this may be considered a form of physical restraint. d. Two fingers should be able to fit underneath the restraint.
a. Restraints provide a reliable method to prevent falls without serious complications.
Which of the following would be a correct action of the NAP in regard to the application of restraints? a. The NAP removes one restraint at a time for a patient who has violent behavior b. The NAP may apply restraints to patients if the NAP determines it is necessary c. The NAP removes the restraints every 24 hours for an hour to perform ROM d. The NAP keeps the patient's bed at a working height while the patient is in restraints
a. The NAP removes one restraint at a time for a patient who has violent behavior
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
a. cooking
A combative patient comes in to the emergency room and is swinging his fists at the nurses. With the assistance of security, the charge nurse places wrist restraints on the patient. What would be a priority action at this time? a. Notify the health care provider for follow-up evaluation. b. Tie the restraint straps in a knot so the patient does not get loose. c. Tie the restraints to the bedside rail or frame of the wheelchair. d. Assess, but avoid removing the restraints every 2 hours because the patient is violent.
a. notify the health care provider for follow-up evaluation
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
a. occupational therapist to evaluate the ability to perform ADLs
The patient's nutrition-related laboratory test results (i.e., ________ and hemoglobin) trend toward normal. a. serum albumin b. intake c. aspiration d. swallowing e. body weight f. refuse g. open h. adaptive utensils
a. serum albumin
A patient who suffered a cerebrovascular accident (stroke) has left sided weakness and facial drooping. As you come into the room, the patient's daughter states, "My mother looks thirsty. Could you bring her some orange juice?" What should you consider before bringing orange juice to this patient? (Select all that apply.) a. How long it has been since the patient experienced the cerebrovascular accident b. Whether the patient requires thickened liquids c. The patient's ability to swallow d. Whether the patient already had orange juice today e. The patient's prescribed diet
b, c, e
The nurse is caring for a patient with a nursing diagnosis of "Activity intolerance related to prolonged bed rest." What should the nurse assess prior to getting the patient out of bed? (Select all that apply.) a. temperature b. blood pressure c. pulse and respiratory rate d. last time patient ate e. patients ability to follow instructions
b, c, e
A hospitalized patient has repeatedly refused her meals. What should the nurse do? (Select all that apply.) a. Administer vitamins with minerals to the patient. b. Determine the patient's food preferences. c. Apply more seasonings to foods. d. Determine whether the patient is in pain. e. Offer to feed patient.
b, d
The nurse is providing an in-service on patient safety and reducing the risk of patient falls. What information should the nurse include in this discussion? (Select all that apply.) a. Wait to toilet high fall risk patients until after they have been medicated for pain. b. Respond promptly to a patient's call light. c. Organize a predictable daily routine that alternates activity and rest for the patient. d. Place soft cotton socks on patient's feet whenever getting them out of bed. e. Keep the bed in a low, locked position.
b, d, e
You are informed that the patient swallows without difficulty but requires assistance with feeding. Which of the following would be appropriate expected outcomes for this patient? (Select all that apply.) a. The patient will be able to feed herself. b. Serum albumin and hemoglobin remain within normal limits. c. Monitor intake and calorie count. d. The patient eats without aspirating food. e. The patient's feeding is paced to avoid fatigue. f. Body weight trends toward normal and stabilizes.
b, d, f
The nurse and NAP are applying extremity restraints to a patient. Which action, if made by the NAP, would require correction? A. The NAP first placed the patient in functional alignment b. The NAP attached the restraint to the side rail of the bed c. The NAP used quick-release tie on the movable bed frame. d. The NAP inserted two fingers under the secured restraint.
b. The NAP attached the restraint to the side rail of the bed
Which f the following patients is at greatest risk for experiencing a fall? a. a recently admitted patient b. a confused patient with a history of a previous fall c. a patient who ambulates by holding onto furniture d. a patient who wears glasses to read
b. a confused patient with a history of a previous fall
Which of the following patients is at greatest risk for experiencing a fall? a. a recently admitted patient b. a confused patient with a history of a previous fall c. a patient who ambulates by holding onto furniture d. a patient who wears glasses to read
b. a confused patient with a history of a previous fall
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
b. a pressure sensor alarm and a room near the nurses' station
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 ad prepare meals d. ability to safely eat without choking
b. ability to safely get on ad off toilet
The patient's ________ improves in the quality of nutrients ingested. a. serum albumin b. intake c. aspiration d. swallowing e. body weight f. refuse g. open h. adaptive utensils
b. intake
The nurse is getting a patient with right-sided weakness up in a chair. On what side of the bed should the nurse place the chair? a. whichever side the patient prefers b. on the patient's left side c. on the patient's weak side d. it doesn't matter because you are assisting the patient
b. on the patient's left side
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
b. urinary incontinence
A patient has severe rheumatoid arthritis affecting her hands. What measures can be taken to facilitate optimum nutrition? (Select all that apply.) a.Provide the patient with finger foods such as raisins, nuts, grapes, and cheese cubes. b. Identify the food location on the plate as if it were a clock. c. Determine the patient's food preferences. d. Provide adaptive utensils (e.g., large handles). e. Attach a plate guard to the plate.
c, d, e
If a patient has dysphagia (difficulty swallowing), which of the following foods found on the patient's tray may be cause for concern or require further intervention? (Select all that apply.) a. Oatmeal. b. Scrambled eggs. c. Grape juice. d. Sausage patty. e. Toast with butter.
c, d, e
Which of the following are appropriate measures to help the patient with dysphagia to swallow and prevent aspiration? (Select all that apply.) a. Provide the patient with a lap protector. b. Talk about other matters while feeding the patient. c. Add thickener to thin liquids. d. Place food on the unaffected side of the mouth. e. Provide verbal coaching. f. Place the patient in the high-Fowler's position.
c, d, e, f
The nurse is caring for an elderly person who has suffered a stroke and now has left-sided weakness and dysphagia. The nurse is being careful to prevent the patient from aspirating by taking which of the following measures? (Select all that apply.) a. Placing the food on the patient's left side of the mouth. b. Placing several tablespoons of food in the patient's mouth following it with liquid prior to having the patient swallow. c. Having the patient tilt her head forward slightly when swallowing. d. Placing the food in the middle of the tongue toward the back of the mouth. e. Having the patient maintain an upright position for 30 to 60 minutes after eating.
c, e
Which of the following patients should be allowed to lie back down? a. A patient whose blood pressure was 120/80 prior to transfer and is now 112/78. b. A patient whose blood pressure was 110/70 prior to transfer and is now 125/80. c. A patient who complains of feeling dizzy and slightly nauseous when sitting on the bedside. d. A patient who was just transferred to a chair and states she was more comfortable in bed. Health care provider's orders are to be up in chair twice daily.
c. A patient who complains of feeling dizzy and slightly nauseous when sitting on the bedside.
A hospitalized elderly patient is disoriented to time and place, and the NAP reports the patient has been pulling at the indwelling catheter. The nurse replaced the Foley catheter an hour ago after the patient pulled it out. After a focused assessment of the patient, the nurse determines the use of restraints is appropriate. Which action should the nurse take next? a. call the patients family and obtain consent for restraints to be applied b. Have the NAP apply restraints and assess application 1 hour later c. Have the NAP stay with the patient and call the healthcare provider d. Apply restraints immediately to prevent disruption of the Foley catheter
c. Have the NAP stay with the patient and call the healthcare provider
The NAP is reviewing with the nurse how to apply a belt restraint. Which statement, if made by the NAP, indicates further teaching is necessary? a. to apply the belt restraint, I should first have the patient sit up in bed. b. a properly applied belt restraint allows the patient to turn onto his side. c. I should place the belt restraint around the chest or abdomen. d. I should apply the belt over the patient's gown or pajamas.
c. I should place the belt restraint around the chest or abdomen
What should the nurse do prior to applying physical restraints? a. Move the patient to a room without a roommate and away from the nurses' station. b. Warn the patient that restraints will be used if he or she does not cooperate. c. Initially, provide a restraint-free environment. d. Wait until the patient has actually fallen.
c. Initially, provide a restraint-free environment.
The patient begins to cough and choke while the nurse is feeding him. What should the nurse do? a. Give the patient some water. b. Allow the patient to rest. c. Suction the airway as necessary. d. Notify the health care provider immediately.
c. Suction the airway as necessary.
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 3-4 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
c. asks the teenager to turn the headphone volume down
The patient coughs appropriately when eating with an absence of signs of ________ or new respiratory compromise. a. serum albumin b. intake c. aspiration d. swallowing e. body weight f. refuse g. open h. adaptive utensils
c. aspiration
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
c. assisting with or performing the patient's ADLs
Why are most health care agencies no longer using vest (jacket) restraints? a. because they are less cost effective than other restraints b. because they are difficult to apply and remove c. because patients are able to get out of them more easily d. because they have been associated with fatal injuries
d. because they have been associated with fatal injuries
You have fed the patient lunch. Besides recording the amount of liquids consumed on an intake and output record, you will make a narrative note in the chart. Which of the following is the most accurate documentation? a. Black b. Green c. Purple d. Blue
d. blue
A 56-year old man who has been staying at a cabin while hunting arrives at the emergency department with complaints of dizziness, light-headedness, and nausea. What does the nurse initially suspect? a. lead poisoning b. radon exposure c. food poisoning d. carbon monoxide poisoning
d. carbon monoxide poisoning
A nurse is determining which type of restraint to apply to a toddler who recently had facial surgery and is pulling at her sutures and oxygen tubing and rubbing her face. Which type of restraint would likely be the least restrictive and most effective? a. Belt restraint. b. Extremity restraint. c. Mitten restraint. d. Elbow restraint.
d. elbow restraint
The patient demonstrates a complete, effective ________ event without retaining food in the mouth. a. serum albumin b. intake c. aspiration d. swallowing e. body weight f. refuse g. open h. adaptive utensils
d. swallowing
The patient's ________ remains stable or trends toward the normal level. a. serum albumin b. intake c. aspiration d. swallowing e. body weight f. refuse g. open h. adaptive utensils
e. body weight
The patient demonstrates increased ability to feed himself or herself or to ________ items on the tray. a. serum albumin b. intake c. aspiration d. swallowing e. body weight f. refuse g. open h. adaptive utensils
g. open
The patient demonstrates the use of ________ as appropriate. a. serum albumin b. intake c. aspiration d. swallowing e. body weight f. refuse g. open h. adaptive utensils
h. adaptive utensils
