Chapter 27 Safety, Security, and Emergency Preparedness Prep U (TTE)

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?" Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function, so the nurse will ask about the child's respiratory status. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach; vomiting should not be induced until more information is gathered. Instructing the parent about leaving the child alone is not therapeutic at this time.

A caregiver of a toddler has called the poison control nurse to report that the child licked a small amount of petroleum jelly. The caregiver states that the toddler is sitting on the floor, watching a cartoon, and playing with a toy. Which information will the poison control nurse provide?

Dilute with water or milk. The decision tree for treating ingested poisons states that if petroleum is ingested, it should be diluted with water or milk, vomiting should be prevented, hydration should be given, and symptoms should be treated. Therefore, it is not appropriate to call 911, induce vomiting, or administer a laxative.

The nurse is caring for a client with a latex allergy. Which nursing interventions are appropriate? Select all that apply.

Flag the chart and room door. Apply an allergy-alert identification bracelet on the client. Communicate to the interdisciplinary health care team to use nonlatex equipment. Teach the client to wear a Medic-Alert bracelet. When caring for a client with a latex allergy, the chart and room should be flagged to reflect the client's status. The nurse will apply an allergy-alert identification bracelet and assign the client to a private room that can be kept free of latex equipment. Other members of the interdisciplinary team should be notified to use nonlatex equipment. Blueberries are not contraindicated for clients with a latex allergy. The nurse will teach the client to wear a Medic-Alert bracelet at all times for safety purposes.

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter. The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard. Taping the electrical cord to the ground and running the electrical cord under the carpet are not appropriate actions for electrical safety.

The nurse has received a medication order over the telephone from a provider. What is the next appropriate nursing action?

Repeat or read back the order. In keeping with National Patient Safety Goals, the nurse will read back the order, then proceed to document the order in the EHR, prepare the medication, and identify the client by two identifiers prior to administration.

The nurse is admitting a client to a medical-surgical unit who states, "If someone brings balloons to me, I might have trouble breathing." What is the appropriate nursing action?

Replace common health care items with latex-free equipment. The client has described a reaction to latex, so the environment should be as free from latex as possible. The nurse will replace all health care equipment with latex-free versions. The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes, not oranges and spinach.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises. The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it.

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

The report provides a detailed and objective account of the circumstances before, during, and after the event. Incident reports are used for internal review and improvements to systems. They include detailed descriptions of the event in question. They do not become part of the client's health record. They are often provided to outside agencies, but they do not bypass the institution where the event occurred. Clients and their families do not sign incident reports.

A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply.

Use filtering software to block objectionable information. Investigate any public chat rooms used by the children. Be alert for downloaded files with suffixes that indicate images or pictures.

The nurse is teaching a nursing student about proper latex glove use. Which teaching will the nurse include?

Wash hands thoroughly after removing gloves with a pH-balanced soap. If latex gloves are used, nurses should wash hands thoroughly after removing gloves with a pH-balanced soap. They should use powder-free, not powdered, gloves. They should not snap gloves when applying them. They should avoid using oil-based hand creams or lotions.

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?

a dose of an antipsychotic Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior Chemical restraints are medications, such as an antipsychotic, that are used to manage a client's behavior or freedom of movement. These are generally used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the client, staff, or others. Physical restraints are devices that immobilize or reduce the ability of a client to freely move his or her arms, legs, body, or head. Asking the UAP to sit with the client is a diversion method. Articulation of rationale for using a physical restraint is part of nursing teaching.

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

automobile accidents. Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers.

A large health care organization has committed to promoting a just culture when adverse events and near misses take place. Which question will guide the organization's response when a nurse commits an error?

"How did the nurse's actions contribute to this error?" Key to the establishment of a just culture is a recognition that not all errors are the same, and that nurses' contributions to errors vary greatly. Legal liability and communication with the client are valid considerations, but none directly promote the establishment of a just culture. It is of little value to learn how other organizations have responded to nurses during similar events once the research phase of establishing a just culture is completed.

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity. Restraints should be sufficiently loose for two fingers to be inserted between the restraint and the extremity. Restraints can be placed on ankles; quick-release knots should be tied to the bed frame, not the side rail. Restraints should be removed every 2 hours.

The nurse is caring for a client with Alzheimer's disease. A family member states, "I am afraid I will go to bed one night, and the next morning my loved one will be missing from wandering off." What is the appropriate nursing response?

"Consider the Alzheimer's Association 'Safe Return' program." The appropriate nursing response is to refer the client's family member to a program such as the Alzheimer's Association's "Safe Return" program. This validates the family member's concern and provides a resource. Validating that clients with this disorder wander does not provide a solution to the concern, and recommending that the family member adjust sleeping schedules is not realistic. The nurse should not verbalize his or her own concerns, but rather should focus on the needs of the client and family members.

The home health nurse is performing fall risk assessments. Which client is identified by the nurse as being a high risk for falls? Select all that apply.

A client taking benzodiazepines A client with poor lighting in the home A client with scatter rugs throughout the home A client with a history of previous falls Major causes of falls in the home include slippery surfaces, poor lighting, clutter, and improperly fitting clothing or slippers. Additionally, polypharmacy has long been listed as a risk factor, but research has indicated that adverse effects related to the use of antiepileptics and benzodiazepines are more predictive of falling. A history of a previous fall has consistently been identified as a predictor of another fall.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

Ask to examine the client alone in order to speak to her privately. In 90% of elder abuse cases that are reported, the person doing the abusing is a family member. The best thing to do would be for the nurse to get the client alone so that she can discuss the relationship that was observed. Documenting the behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury to the client. The nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols.

When educating parents about the safety of preschool-aged children, which is most important for the nurse to include in the presentation?

At home chemicals should be kept in a locked cabinet. Increasing mobility, lack of life experience and judgment, and immature musculoskeletal and neurologic systems lead to potentially hazardous encounters for toddlers and preschool-aged children. Parents must be taught to keep chemicals in a locked cabinet to reduce exposure. Weapons should be secure, preferably in locked gun cabinets to prevent access by children. The recommended safety equipment for sports should be used by people of all ages to prevent injury, not to decrease fear.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler. The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious. Monitoring the activities of the toddler is not always feasible. Allowing the child to swim with friends does not ensure safety.

Which item would alert the home care nurse to a safety hazard threatening a young child?

Dangling blind cords As babies gain neurologic and musculoskeletal functions, they learn and explore by pulling objects to themselves and placing almost everything in their mouths. Cords, tablecloths, plastic bags, bottles, and cans are tempting, dangerous objects that caregivers must strive to keep out of reach.

A nurse is using the DAME acronym to perform fall assessments on older adults in a home health care setting. Which examples of nursing actions follow this guideline? (Select all that apply.)

D—A nurse assesses drug and alcohol use of the patients. A—A nurse assesses the age-related physiologic status of the patients. M—A nurse reviews patient charts for medical problems affecting falls. Home health care nurses frequently use the acronym DAME to assess the risk for falling in older adults at home. The D stands for drug and alcohol use; the A stands for age-related physiologic status; the M is for medical problems; and the E represents environment.

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

Initiate use of a bed alarm. To prevent a fall, the nurse should attempt to prevent the confused client from getting out of bed by himself by using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all four side rails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort when the client is in danger of harming himself or others. Contacting the physician for a restraint order or sedative is appropriate if the least restrictive measures do not work.

What best describes the nurse's role in disaster preparedness?

Multiple roles, including triage and the distribution of resources Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

Placing the client in a bed with a bed alarm Raising all side rails on the bed would be a restraint, and may increase the client's risk of a fall if he or she climbs out of bed. Providing a bed that is elevated would put the client at a greater risk for a fall. Using restraints are not an option at this time, but placing the client in a bed with a bed alarm would help to prevent a fall.

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment.

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

Risk for Injury Related to Agitation The client's risk of self-injury or injury to others is the justification for restraint use. Restraints are not normally used to address noncompliance or chronic confusion unless there is a consequent safety risk. Impaired bed mobility is not a justification for restraints.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

The nurse should record the incident in the client's medical record and fill out a safety event report separately. The nurse completes the safety event report immediately after an unintentional injury and is responsible for recording the incident and its effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. The nurse should not wait until after the x-ray to complete the form.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others. The client should be released from the restraint as soon as he or she is no longer a risk to self or others. Decisions should be based on the client's present status, not on his or her history. Restraints must be ordered by a health care provider and the least restrictive device should be used.

An administrative assistant at a large factory visits the medical unit and tells the nurse she is having pain in the right wrist, numbness in the index finger, and decreased mobility of the right hand. The nurse suspects the client has:

carpal tunnel syndrome. Adults with jobs that require repetitive movement (typists, assembly line workers, supermarket checkers, computer operators) may develop carpal tunnel syndrome, a compression of the median nerve that causes pain and decreases hand mobility. A fracture would most likely be accompanied by symptoms including pain, swelling, and an inability to use the extremity. A herniated cervical disk would likely be accompanied by symptoms involving numbness and discomfort of the neck and arms. There are no manifestations consistent with an infection in the bone.

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

"I will rescue clients from harm before doing anything else." The RACE acronym should be used when managing a fire: Rescue, Alarm, Confine, and Extinguish. Teaching has been effective when the UAP knows to rescue patients first.

When educating families on fire safety, it is important to:

have a meeting place outside the home. The whole family should regularly practice crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in an area with access and not a closet.

A nurse visits an older adult client at home and assesses the safety of the client's environment. Multiple small rugs are located in the home. Which statement by the nurse is appropriate when addressing the client's safety?

"I am concerned that the small rugs in your home can be a tripping hazard." The nurse can open up the conversation by stating concern about the small rugs. The conversation provides education through problem-solving. If the nurse demands or states generalities, the nurse will not gain the needed cooperation from the client. The older adult client should remove all area rugs, even if skid resistant, to prevent accidental injury.

There is a fire in the trashcan in the client's room. What is the nurse's first priority?

Remove the client from the room. The priority would be to remove the client from immediate danger. The acronym for health care facility fire safety is RACE, which stands for rescue, alarm, confine, and evacuate.

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for a 9-month-old infant?

"We place our baby in a rear-facing car seat in the back seat of the car." Children from birth to 2 years of age should remain in a rear-facing infant seat in the back seat of the car until they reach the maximum height and weight for a front-facing child car seat.

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group?

Use protective sporting equipment. School-age children in the 7th grade are physically active, which makes them prone to play-related injuries. Therefore, protective sporting equipment should be used. Information about not texting while driving is more appropriate for teenagers and adults who drive. Using caution around electrical outlets and stairs is more appropriate for parents of toddlers.

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

Implement drowning prevention strategies. The principles of injury control have interventions centered at three primary levels: the individual level--providing education about safety hazards and prevention strategies; the design phase--using engineering and environmental controls; and the regulatory level--creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users. Although the nurse's role would fit into the individual level of providing education, it is not the nurse's responsibility to teach cardiopulmonary resuscitation or swimming in this scenario. As the nurse's role does not include the design phase or regulatory level, it is not a nursing responsibility to require fencing around all pools.

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

Restrain the baby in a car seat. The client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets, giving warm bottles of formula to the baby, and keeping all pots and pans in lower cabinets are secondary teachings.

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

Social pressure As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment.

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use?

19-year-old male college student majoring in physics Young adults, particularly those who just became emancipated from parental supervision, are at the highest risk for alcohol and drug use. Other clients may have other safety risk factors, but are not at a proportionately higher risk for alcohol and drug use.