Fundamentals Exam 1 Ch. 27

Which level of health care provider may make the decision to apply physical restraints to a client? a. nurse practitioner b. senior personal care assistant c. LPN team leader d. RN nurse manager

a. nurse practitioner Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such as The Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician assistant.

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. Gun safety b. Smoking cessation c. Fire safety d. Childproofing the house

c. Fire safety

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. Cough, dyspnea, and fatigue c. Nausea, vomiting, and diarrhea d. Abdominal pain and hematemesis

B. Cough, dyspnea, and fatigue

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse? a. Assess the client for signs and symptoms of osteoporosis b. Arrange for a skilled home care assessment c. Arrange an audiology consult to evaluate hearing d. Perform a vision test with Snellen chart

D. Arrange for a skilled home care assessment The client's home should be evaluated for potential hazards and risks. There is no indication of vision or hearing issues. It is uncommon for falls to be directly attributable to osteoporosis.

The nurse is teaching the caregiver of an infant about safety. Which teaching will the nurse include? a. Place all household cleaners out of reach. b. Supervise your child on the changing table. c. Buy protective sporting equipment. d. Peer pressure causes children of this age to take risks.

Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Therefore, the nurse teaches the caregiver to supervise the child on the changing table. Placing household cleaners out of reach, buying protective sporting equipment, and teaching about peer pressure risks are appropriate for older children, not infants.

The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply. a. Obtain order from a licensed provider within minutes of restraint application. b. Offer regular, frequent opportunities for toileting. c. Check circulation and skin condition every 2 hours. d. Withhold information from family regarding restraints due to HIPAA. e. Maintain restraints until discharge.

Obtain order from a licensed provider within minutes of restraint application. Check circulation and skin condition every 2 hours. Offer regular, frequent opportunities for toileting. An order for restraints from the licensed health care provider must be obtained within minutes after the restraint is applied. Frequent and regular nursing assessments are required of the restrained client's vital signs; circulation; skin condition or signs of injury; psychological status and comfort; and readiness for discontinuing the restraint. The nurse must explain the need for restraints with the family. When the assessment findings indicate that the client has improved, restraints must be removed.

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply. a. Ensure appropriate lighting in hallways and entrances to the home. b. Store prescription medications on the counter. c. Check the batteries in all smoke detectors. d. Remove extension cords from open spaces. e. Remove throw rugs from high traffic areas.

Remove extension cords from open spaces. Check the batteries in all smoke detectors. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas. Nursing assessment includes identifying individuals at risk and recognizing unsafe situations in the environment. Assessment includes an awareness of risk factors in the home. The nurse would advise the client to remove extension cords from open spaces, check the batteries in smoke detectors, remove throw rugs, and ensure appropriate lighting in hallways and entrances to the home. The nurse would not advise the client to place prescription medications on the counter as anyone could access these. It is recommended that medication be kept in a place that is easy for the client to access, but still should be kept out of the reach of children or others who may take them.

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

The client is wearing the oxygen around the neck. There is spilled water on the floor. The IV is not infusing at the correct rate. The skin is a bluish-color. The situational assessment includes: ABCs, IVs, tubes, oxygen, safety, and environmental safety, including the nurse's intuition, hearing, smelling, seeing, or feeling that something needs to be explored. The client wearing oxygen around the neck is a concern in a situational assessment, because the client's SpO2 may be decreased if the oxygen is not worn properly. Moreover, tubing around the neck presents a safety issue, as does spilled water on the floor. The client's television is of no importance to the situational assessment. The situational assessment should check whether the IV is infusing at a correct rate. The client's skin being a bluish color is also a concern during situational assessment; it could be related to not wearing the oxygen correctly or indicate coldness or lack of perfusion.

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? a. Individualize the use of restraints and choose the most easily used device. b. 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. c. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. d. Respond to the past history of the client (including previous falls) to determine the need for restraints.

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.

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? a. Fifth b. Tenth c. First d. Eighth

Unintentional injuries are the fifth leading cause of deaths behind heart disease, cancer, stroke, and chronic obstructive lung disease. Listed are the top 3 leading causes of death in the US: Heart disease, cancer, and chronic lower respiratory diseases.

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention? a. "Only certain members of the health care team can extinguish a fire." b. "I will rescue clients from harm before doing anything else." c. "I will close the door to the room where the fire is after clients have been removed." d. "After clients are evacuated from the room with the fire, the alarm can be sounded."

a. "Only certain members of the health care team can extinguish a fire." All members of the health care team are educated about how to extinguish a fire. Therefore, the UAP's statement about certain members being taught how to use the fire extinguisher requires correction. The other statements are appropriate.

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? a. New systems are introduced to increase communication between nurses and the members of other health disciplines. b. Hiring practices are reviewed to maximize the proportion of nurses who possess baccalaureate or graduate degrees. c. Systems are reviewed with the goal of achieving the best client outcomes at the lowest cost. d. New partnerships are established between the hospital and local schools of nursing.

a. New systems are introduced to increase communication between nurses and the members of other health disciplines. Teamwork and collaboration is one of the core QSEN competencies, and is exemplified by increasing communication between different disciplines. The six QSEN competencies do not explicitly address financial costs of care, higher levels of education for nurses, or increased partnership between hospitals and educational institutions.

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 may be developing nutritional deficiencies from poor dietary habits. d. She has lost interest in academics because she has a boyfriend now.

a. She may be the victim of cyber-bullying Symptoms of cyber-bullying include faltering school achievement, absenteeism, health concerns, isolating oneself from peers/friends, and increased anxiety and depression symptoms. Adolescents may neglect academics when involved in personal relationships, but that is a common milestone of the age group. Achieving menarche may alter mood, but it is not a risk concern. Nutritional deficits can be seen in adolescence and may need to be investigated with this client, but it is not the priority at this time.

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply. a. Teamwork and collaboration b. Establishment of clinical career ladders c. Quality improvement (QI) d. Revamping the licensing requirements for foreign-educated nurses e. Client-centered care

a. Teamwork and collaboration c. Quality improvement (QI) e. Client-centered care The Quality and Safety Education for Nurses (QSEN) project has been designed to provide a framework for the knowledge, skills, and attitudes necessary for future nurses. The six competencies include client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Requirements for foreign-educated nurses and the establishment of clinical career ladders are not explicit focuses of the QSEN competencies.

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? a. administering medications to the client b. electronically reporting the results of diagnostic testing to the client's primary care provider c. admitting the client to the health care facility d. transferring the client from one location in the hospital to another

a. administering medications to the client A large proportion of adverse events in hospital settings involves medication administration. It is generally accepted that medication administration is more risky than communication of testing results, client transfers, or client admissions.

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? a. provides slippers for ambulation b. places bed at lowest setting c. clears a path from bed to bathroom d. has client sit in bed for a few moments before standing

a. provides slippers for ambulation Older adults often wear slippers to accommodate swollen feet. Although slippers are more comfortable, less expensive, and less tiring to put on than shoes, they do not offer much support or traction. The nurse should intervene to remind the UAP that better footwear should be utilized. Placing the bed at the lowest setting, clearing a path from the bed to the bathroom, and having the client sit in bed before standing increase safety while minimizing risk for falls.

The nurse is making the initial assessment of a client following a surgical procedure with sedation. Place in order the nurse's assessment actions. Use all options. 1items within the client's reach 2level of consciousness and orientation 3intravenous access and IV fluids 4wounds and tubes 5airway, breathing, and circulation

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

The nurse is 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. Outlets and switches have cover plates. b. A hair dryer is placed next to the sink. c. No extension cords are being used. d. Machines used infrequently are unplugged.

b. A hair dryer is placed next to the sink. Electrical shock can result if appliances such as a hair dryer come in contact with water. The hair dryer should be removed away from the sink. Other findings reflect appropriate safety measures.

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. a. Type of health care facility b. Communication ability c. Developmental level d. Mobility e. Community population

b. Communication ability c. Developmental level d. Mobility Nurses should be stewards of a safe environment. In order to promote safety and prevent injuries, nurses must be aware of factors that impact the safety of clients. Some of those factors include the client's developmental level, lifestyle, mobility, sensory perception, knowledge level, communication ability, physical health state, and psychosocial state. The community's population and the type of facility that the client is in should not impact the safety of the client.

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? a. Chronic Confusion Related to Long-Standing Alcohol Use b. Risk for Injury Related to Agitation c. Noncompliance Related to Medication Regimen d. Impaired Bed Mobility Related to Muscle Wasting

b. 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 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. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old and weighing less than 20 lb (9 kg). b. A rear-facing safety seat should be used for infants younger than 1 year old or up to the maximum weight for the seat. c. A rear-facing safety seat should be used for infants younger than 1 year old and weighing more than 20 lb (9 kg). d. 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.

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

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 provides an opinion of the physical and mental condition of the client that may have precipitated the incident. b. The nurse details the client's response and the examination and treatment of the client after the incident. c. The nurse calls the primary health care provider to fill out and sign the safety event report. d. The nurse adds the information in the safety event report to the client health record.

b. The nurse details the client's response and the examination and treatment of the client after the incident. An unintentional injury or incident that compromises safety in a health care agency requires the completion of a safety event report (incident report). The nurse completes the event report immediately after the incident and is responsible for recording the circumstances and the 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 physician is not responsible for filling out or signing the safety report unless she witnessed the incident. The nurse reports factual information, not opinions.

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

b. 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 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. Increased thirst b. Vomiting c. Drowsiness d. Headache e. Fever

b. Vomiting c. Drowsiness d. Headache Concussions are a frequently seen sports injury in school-age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present. Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms usually seen with a concussion.

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

c. "Make sure that you have smoke detectors in your house and that they're in working order." A paramount fire-safety issue is smoke detectors, since approximately half of home fire deaths occur in a home without a smoke detector. This risk far exceeds that of fireplaces, even though these must be used with caution. Individuals should stop, drop and roll if clothing catches on fire. Old microwaves do not constitute a significant fire risk.

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. a. Participates in a walking club b. Shares a one floor living space with a spouse c. Admits to drinking wine through the evening d. Has history of diabetic neuropathy e. Takes furosemide daily

c. Admits to drinking wine through the evening d. Has history of diabetic neuropathy e. Takes furosemide daily The acronym DAME (Drug/alcohol use, Age-related physiologic status, Medical problems, Environmental) assists the nurse to asses fall risk at home. The diuretic furosemide may cause the client to fall during frequent and possibly urgent trips to the toilet. Furosemide may also cause volume depletion and dizziness in standing. Diabetic neuropathy contributes to falls because of loss of normal sensation in feet and lower extremities. Consuming alcohol contributes to loss of balance, volume depletion and urinary urgency. Living on one floor and performing regular exercise describe positive characteristics for fall prevention.

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

c. Conceal IV tubing with gauze wrap Wrapping the IV line provides protection for the site. Medications used to control behavior can be considered a chemical restraint that is an intervention of last resort. The presence of a family member may assure client safety and alleviate client anxiety, but would not necessarily protect the IV site. As well, it is inappropriate to delegate client safety observation to family members. Bed alarms alert the nurse to the client leaving his or her bed, but not interference with the IV site.

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. Collaborate with the resident's health care provider to have his or her diuretics discontinued. c. Investigate the possibility of discontinuing his or her catheter. d. Increase the resident's physical activity to reduce evening restlessness.

c. Investigate the possibility of discontinuing his or her catheter. Discontinuing the catheter, if medically prudent, would eliminate the risks associated with the resident's behavior. Limiting fluid intake or reducing diuretics would be unsafe and ineffective. Similarly, increasing the resident's activity is unlikely to reduce restlessness.

A nurse makes a medication error and reports it to the nurse manager, requesting assistance filling out the incident report. What should the nurse manager educate the nurse about regarding the incident report? Select all that apply. a. Completion of the incident report should be noted in the nurse's notes. b. The incident report should be placed with the client's health records. c. It should include factual information about the incident. d. It should provide a clear, concise recording of the situation e. The nurse should include a personal perception about the cause of the incident

c. It should include factual information about the incident. d. It should provide a clear, concise recording of the situation An unintentional injury occurring in the hospital necessitates the filing of an incident report. The document remains confidential and is not part of the client's medical record. It completely describes all the aspects of the event that occurred. Specifically, the report should include the accident, client assessment, and interventions provided for the client. The report is used for internal review to improve the system to prevent similar errors and cannot be subpoenaed by a court of law.

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? a. Recommend that carbon monoxide detectors be installed in the home. b. Wait inside until emergency personnel arrive. c. Open doors and windows. d. Allow emergency personnel to apply oxygen.

c. Open doors and windows. Carbon monoxide (CO) is extremely lethal because it is colorless, odorless, and tasteless. The nurse recognizes symptoms of bright cherry red skin color, nausea, headache, and inability to move. The initial direction will be for the caller to open doors and windows to reduce the level of toxic gas and provide adequate ventilation. If, while waiting for emergency personnel to arrive, the family members gain the ability to move, they can evacuate outdoors. After having the caller open doors and windows, the nurse can then provide instructions about emergency personnel and further discuss CO detectors.

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? a. Promptly document the change in client status b. Apply limb restraints to ensure client safety c. Reduce distressing environmental stimuli to maximize client safety d. Leave to notify the health care provider concerning a change in client status

c. Reduce distressing environmental stimuli to maximize client safety Added stimulation can increase the maladaptive behaviors of the client; therefore, the nurse should first reduce the distressing environmental stimuli. Proper communication of client status change is a legal requirement of nurses, and documentation provides a means of communication between interdisciplinary teams and provides continuing of care. However, notifying the health care provider and documenting the change in status are not the priority action. Restraints are to be used as a last resort in client care.

The nurse is discussing car safety with the mother of a 6-year-old child. The child's mother questions the need for the use of special car seats for her child. What information can be provided to her? a. "Car seats are only recommended until children are 3 years old." b. "Your child will be safe in the car using the provided shoulder harness and lap belts." c. "Car seats are recommended until children are at least 10 years old." d. "At the age of 6 your child should be using a booster seat."

d. "At the age of 6 your child should be using a booster seat." When children outgrow standard car seats, parents and caregivers should use booster seats, preferably those that use combination shoulder and lap belts, until the car seat belt fits appropriately (typically when they have reached 4 ft, 9 in [1.43 m] in height and are between 8 and 12 years of age).

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. Activate the fire alarm on the unit. b. Attempt to extinguish the fire. c. Evacuate clients and staff. d. Rescue anyone who is in immediate danger.

d. Rescue anyone who is in immediate danger. The acronym "RACE" can be used as a guide to the immediate response to fire. This involves rescuing anyone in immediate danger (R); pulling the alarm, calling "code red," and alerting appropriate personnel (A); confining the fire by closing doors and windows (C); evacuating clients and other people to a safe area (E). Extinguishing the fire is not part of the immediate response.

Which factor is related to the highest proportion of falls in long-term care settings? a. Polypharmacy b. Agitation c. Impaired sleep patterns d. Toileting

d. Toileting More than 42% of falls in an acute care agency were toileting related, often involving getting out of bed or ambulating to the bathroom, slipping from the toilet or commode, or standing to use the urinal. This exceeds the role of other variables, including agitation, polypharmacy and impaired sleep.

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? a. reinforcing the standards for nursing care to staff members who were involved b. ensuring that the client's nurse is held accountable and educated about best practice c. communicating the potential consequences of the near miss to the client involved d. identifying systemic factors on the unit that may have contributed to the event

d. identifying systemic factors on the unit that may have contributed to the event Central to creating a culture of safety is the need to identify systemic factors that may contribute to errors or near misses. Communicating with the client is necessary, but identifying systemic factors is a priority because of the implications for future clients. Focusing on the nurses who were directly involved demonstrates a narrow and short term perspective of safety, which may be perceived as punitive.

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: a. the client's future qualification for Medicare and/or Medicaid. b. the hospital's standing in the Magnet Recognition Program. c. the hospital's evaluation by the Occupational Safety and Health Administration (OSHA). d. the amount of money the hospital receives from the Centers for Medicare & Medicaid Services.

d. the amount of money the hospital receives from the Centers for Medicare & Medicaid Services. A portion of the value-based purchasing program is based on clients' responses to satisfaction surveys such as HCAHPS. This survey is irrelevant to the client's enrollment in Medicare or Medicaid. OSHA is not privy to HCAHPS results. HCAHPS results are not used in the determination of Magnet designation.