Chp 27 PrepU-Safety, Security , and Emergency Preparedness

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client? A. Initiation of a peripheral intravenous (IV) line for fluid administration B. Assessment of vital signs and respiratory status C. Assessment of head circumference D. Evaluation of all of his cranial nerves

B. Assessment of vital signs and respiratory status

A nurse is teaching parents about Internet safety for children. Which actions are recommended guidelines 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.

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

Dangling blind cords

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?

Involve family members in the client's care.

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?

New systems are introduced to increase communication between nurses and the members of other health disciplines.

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include?

Peer pressure causes children of this age to take risks

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take? -Confine the fire. -Extinguish the fire. -Pull the fire alarm lever. - Evacuate the unit.

Pull the fire alarm lever.

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first?

Reduce distressing environmental stimuli to maximize client safety

A nurse is caring for an 18-month-old client after a tracheostomy. The is recovering well and noted a desire to be more active. The nurse selects a toy from the playroom for the client to play with. Which toy is most developmentally appropriate?

a rocking horse

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client?

an 84-year-old male with four recent driving violations

A nurse visits an older adult client at home and assesses the safety of the client's environment. Which article can be a threat to the client's safety?

area rugs kept on the stairs without carpet

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

fill out an incident report, with the goal of preventing a similar event in the future.

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

identifying systemic factors on the unit that may have contributed to the event

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers

The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include:

polypharmacy and use of multiple extension cords.

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

A hair dryer is placed next to the sink.

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

A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to:

experimentation with drugs and inhalants.

What is the primary role of the nurse in the care of clients who experience domestic violence? A. Serving as a witness in court B. Calling the police C. Providing prompt recognition of the potential or actual threat to safety D. Identifying health education and counseling measures for the family

C. Providing prompt recognition of the potential or actual threat to safety

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? A. Raising all the side rails of the bed B. Using restraints on the client to prevent a fall C. Providing a bed that is elevated from the floor D. Placing the client in a bed with a bed alarm

D. Placing the client in a bed with a bed alarm

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation rather than burns.

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.

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?

A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat.

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse?

Arrange for a skilled home care assessment

The older client tells the nurse that the client needs to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety?

administering medications to the client

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age? A. "Always provide close supervision for young children when they are in or around pools and bathtubs." B. "Never smoke in the bed in the house when young children are present." C. "Store medications in a locked area to prevent children from getting into them." D. "Never keep firearms in the home with young children."

A. "Always provide close supervision for young children when they are in or around pools and bathtubs."

A nurse is caring for older adult clients. Which is the most important safety issue in older clients? A. accidental falls B. poisoning C. electrical injury D. drowning

A. accidental falls

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide?

Open doors and windows.

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected the client with an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident?

Report this sentinel event to the Joint Commission and to relevant state agencies

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

"I should be able to fit two fingers between my chin and the chin strap."

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?"

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply.

-Takes furosemide daily -Admits to drinking wine through the evening -Has history of diabetic neuropathy

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options.

1. Explain rationale for use to the client and family. Pad bony prominences. 2. Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. 3. Ensure that two fingers fit between the restraint and the client's skin. 4. Position limbs in normal anatomic position. 5. Secure restraints to the bed frame with quick-release knots.

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? A. Attempt to extinguish the fire. B. Rescue anyone who is in immediate danger. C. Evacuate clients and staff. D. Activate the fire alarm on the unit.

B. Rescue anyone who is in immediate danger

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: A. falls from staircases. B. automobile accidents. C. falls from beds. D. play-related injuries.

B. automobile accidents.

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? A. Allow the child to swim with friends. B. Instruct the toddler not to go near the pool. C. Avoid unattended baths for the toddler. D. Monitor the activities of the toddler.

C. Avoid unattended baths for the toddler

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan? A. Smoking cessation B. Gun safety C. Childproofing the house D. Fire safety

C. Childproofing the house

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock? A. All machines that are used infrequently are to remain plugged in. B. Leave outlets and switches open so air circulates through them. C. Refrain from using extension cords. D. Remove the plug from the wall by pulling the electric cord.

C. Refrain from using extension cords.

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? A. Assure bed alarms are activated B. Request a sedative from health care provider C. Ask visiting family member to stay D. Conceal IV tubing with gauze wrap

D. Conceal IV tubing with gauze wrap

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death?

Fifth

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

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

have a meeting place outside the home.

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls?

provides slippers for ambulation

A client has been discharged from the hospital after being treated for a myocardial infarction. The client has been asked to evaluate the care received by completing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The results of this survey may affect:

the amount of money the hospital receives from the Centers for Medicare & Medicaid Services.

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important? "If your clothes should catch on fire, go to an open area as quickly as possible." "Make sure that your family's microwave oven was made after 1999; otherwise, it may be a fire risk." "Make sure that you have smoke detectors in your house and that they're in working order." "A wood-burning fireplace is a major fire risk, and it shouldn't be used unless necessary."

Make sure that you have smoke detectors in your house and that they're in working order."

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk? A. She may be the victim of cyber-bullying. B. She may be beginning her menses. C. She has lost interest in academics because she has a boyfriend now. D. She may be developing nutritional deficiencies from poor dietary habits.

A. She may be the victim of cyber-bullying.

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety? A. "Parents are effective role models for children when they also wear helmets while riding." B. "The chin strap on the helmet should be adjusted to fit loosely so that it does not choke the child." C. "Any helmet is appropriate for bicycle riding because all children should wear helmets when riding." D. "Young children secured in a bicycle passenger seat do not have to wear a helmet."

A."Parents are effective role models for children when they also wear helmets while riding."

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic? A. Require fencing around all pools. B. Implement drowning prevention strategies. C. Educate children in cardiopulmonary resuscitation. D. Begin swim lessons with toddlers.

B. Implement drowning prevention strategies

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? A. Limit the resident's fluid intake in order to reduce his or her urge to void. B. Investigate the possibility of discontinuing his or her catheter. C. Collaborate with the resident's health care provider to have his or her diuretics discontinued. D. Increase the resident's physical activity to reduce evening restlessness.

B. Investigate the possibility of discontinuing his or her catheter.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? A. A verbal prescription for the restraints, renewed every 48 hours B. The type of personal protective equipment used by the nurse during restraint application C. The alternative measures attempted before applying the restraints D. A detailed description of the restraint application process

B. The alternative measures attempted before applying the restraints

A school nurse is teaching a group of adolescents about safe driving. What behaviors should the nurse encourage in order to help prevent motor vehicle accidents? Select all that apply. A. Drive at night when fewer people are on the road. B. Never text while driving. C. Always wear a seat belt. D. Obey the speed limit. E. Limit the number of other adolescents in the car.

C. Always wear a seat belt. E. Limit the number of other adolescents in the car. B. Never text while driving. D. Obey the speed limit.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply. A. Headache B. Fever C. Drowsiness D. Vomiting E. Increased thirst

C. Drowsiness A. Headache D. Vomiting

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care? A. Wash the eyes with a hypertonic solution for at least 30 minutes. B. Flush the eyes with a cool saline solution for a 10-minute period. C. Flush the eyes with water for 10 minutes. D. Advise the client to avoid blinking until after the eyes are irrigated.

C. Flush the eyes with water for 10 minutes.

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? A. Administer the client's sedative as ordered. B. Contact the physician for a restraint order. C. Initiate use of a bed alarm. D. Put up all four side rails on the bed.

C. Initiate use of a bed alarm.

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care? A. Altered Sensory Perception related to decreased visual acuity B. Risk for Injury related to substance use C. Risk for Poisoning related to poor eyesight and the inability to read medication labels D. Risk for Falls related to immobility

C. Risk for Poisoning related to poor eyesight and the inability to read medication labels

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? A. The hospital will be fined by CMS because the client developed a pressure injury. B. CMS will bear the hospital's costs if the client chooses to sue the hospital. C. The hospital must bear any costs incurred for treating the client's injury. D. CMS may choose to divert clients to other health care facilities in the future.

C. The hospital must bear any costs incurred for treating the client's injury.

A client is brought to the emergency department after inhaling a substance suspected to be anthrax from the contents of an envelope. What symptoms experienced by the client would the nurse correlate with this substance? A. Ulcerated skin lesions B. Abdominal pain and hematemesis C. Nausea, vomiting, and diarrhea D. Cough, dyspnea, and fatigue

D. Cough, dyspnea, and fatigue

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? A. Accompany the client to the bathroom every 4 hours around the clock. B. Obtain an order for insertion of an indwelling urinary catheter. C. Limit the client's fluid intake during the evening. D. Provide a bedside commode and ensure adequate lighting.

D. Provide a bedside commode and ensure adequate lighting.

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? A. Lock all cabinets that contain cleaning supplies. B. Give warm bottles of formula to the baby. C. Keep all pots and pans in lower cabinets. D. Restrain the baby in a car seat.

D. Restrain the baby in a car seat.

A nurse is assessing a client who was exposed to botulism from contaminated food supplies. Which symptom would the nurse expect to find in this client? A. Skin lesion with local edema that progresses, enlarges, ulcerates, and becomes necrotic B. Petechial hemorrhages C. Flu-like symptoms D. Skeletal muscle paralysis that progresses symmetrically and in a descending manner

D. Skeletal muscle paralysis that progresses symmetrically and in a descending manner

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? A. Poor judgment B. Normal rebellion C. Past experience D. Social pressure

D. Social pressure

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply. A. There is spilled water on the floor. B. The client's television is turned off. C. The IV is not infusing at the correct rate. D. The client is wearing the oxygen around the neck. E. The skin is a bluish-color.

D. The client is wearing the oxygen around the neck. A. There is spilled water on the floor. C. The IV is not infusing at the correct rate. E. The skin is a bluish-color.

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? A. The nurse should contact the facility's social services department. B. The nurse should notify the primary care physician about the bruises. C. The nurse should request permission from the client to photograph the bruises. D. The nurse should question the client about the source of the bruises.

D. The nurse should question the client about the source of the bruises.

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? A. asking the unlicensed assistive personnel (UAP) to sit with the client B. articulating the reason for use of a physical restrictive device to the client's spouse C. application of devices that reduce the client's ability to move arms D. administration of an antipsychotic agent to alter the client's behavior

D. administration of an antipsychotic agent to alter the client's behavior

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.

-Communication ability -Developmental level -Mobility

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

The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse? A. "Check breathing and heart rate." B. "Induce vomiting while you wait for emergency personnel to arrive." C. "What do you think that the child might have ingested?" D. "At what time did the child ingest the substance?"

A. "Check breathing and heart rate."

The facility is conducting an educational seminar for newly employed nurses. The program addresses the reporting of sentinel events. Which occurrences qualify for this criteria? Select all that apply. A. A client reports plans to file a complaint concerning the amount of time it took for a nurse to respond to a call light. B. A client's baby is misidentified and receives breast milk from another mother. C. A client faints during ambulation with the nurse, resulting in a concussion. D. A client experiences a reaction to a unit of blood, resulting in itching and hives. E. The nurse administers a lethal dosage of medication in error.

B. A client's baby is misidentified and receives breast milk from another mother. C. A client faints during ambulation with the nurse, resulting in a concussion. E. The nurse administers a lethal dosage of medication in error.

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? A. Document the observed behaviors in the client's chart. B. Ask to examine the client alone in order to speak to her privately. C. Report the suspicions to to the authorities. D. Nothing, as it is none of the nurse's concern.

B. Ask to examine the client alone in order to speak to her privately

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process? A. The nurse adds the information in the safety event report to the client health record. B. The nurse calls the primary health care provider to fill out and sign the safety event report. C. The nurse details the client's response and the examination and treatment of the client after the incident. D. The nurse provides an opinion of the physical and mental condition of the client that may have precipitated the incident.

C. The nurse details the client's response and the examination and treatment of the client after the incident.

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 3-year-old child? A. "We place our child in a rear-facing car seat in the back seat of the car." B. "We place our child in a rear-facing car seat in the front of the car." C. "We place our child in a front-facing car seat in the front of the car." D. "We place our child in a front-facing car seat in the back seat of the car."

D. "We place our child in a front-facing car seat in the back seat of the car."

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? A. Use an extension cord to provide freedom of movement. B. Tape the electrical cord of the pump to the floor. C. Run the electrical cord of the pump under the carpet. D. Obtain a three-prong grounded plug adapter.

D. Obtain a three-prong grounded plug adapter.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? A. Talk with the client's family about taking her home because she is out of control. B. Sedate her with sleeping pills and leave the restraints on. C. Leave the restraints on and talk with her, explaining that she must calm down. D. Take the restraints off, stay with her, and talk gently to her.

D. Take the restraints off, stay with her, and talk gently to her.

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

The nurse is caring for a young child in the hospital who is being discharged home with his grandmother, who has guardianship. When performing a risk assessment, the nurse identifies that his grandmother has one other adult living with her to help with the child, because the grandmother has congestive heart failure and diabetes mellitus. In addition, the financial situation is poor and she cannot afford to buy safety devices to safety-proof the house. What nursing diagnosis is most appropriate for this child based on these findings?

Risk for Poisoning related to medications in unlocked cabinets

The nurse begins a shift and finds that the wrong medication has been administered to a client. After completing a safety event report, what should the nurse do next?

Submit the safety report to the appropriate department within the facility so that it can be reviewed.

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 should include a note on the client's chart that mentions the report. - The nurse should await results of the x-ray before filing the report. -The nurse should make a copy of the safety event report and place it in the client's medical record.

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

Use the call bell for any needs and wear nonslip footwear."