Fundamentals of Care: Safety

Explore the adolescent's knowledge of gun safety.

An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which as a first step for the prevention of future injury?

Removing any toy with bright blinking lights Keeping the sides rails of the child's bed padded Turning the infant on the side during any seizure Having oxygen and suction available at the bedside

A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by implementing which interventions? Select all that apply.

Avoid activities that involve pulling or pushing. Do not lift objects weighing more than 5 pounds. Do not climb stairs until after the follow-up appointment with the surgeon

A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal implant. The nurse includes which instructions about activity after discharge? Select all that apply.

Let me go over your prescribed medications with you again."

A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic?

Monitoring the skin around the stoma site for skin irritation, Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube

A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client? Select all that apply.

Gown and gloves

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?

A bottle of alcohol

A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the UAP obtains which unnecessary item(s)?

Placing the heating pad under the client

A primary health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?

Aspirin Furosemide' Gentamycin

A seriously ill client in the hospital tells the nurse that he thinks he has lost some of his ability to hear over the past few days. The nurse reviews the medications the client is currently receiving. Which medications are known to be ototoxic? Select all that apply.

Time the start and stop of the seizure. Apply oxygen at 2L with nasal cannula. Turn the client to the side and do not restrain. Note the distinguishing characteristics of the seizure. Turn on the suction machine with oral catheter.

The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply.

Place two fingers under the restraint to determine snugness.

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive?

High-Fowler's position Slight extension of the neck

The nurse assists a primary health care provider (PHCP) with the insertion of a nasogastric tube. Which positions should the nurse place the client in to prepare for the procedure? Select all that apply.

Positioning the client supine Using products with lemon or alcohol

The nurse is administering mouth care to an unconscious client. The nurse should avoid doing which actions? Select all that apply.

Place a gait belt on the client. If stretch bands are used, reinforce the correct use. Observe for any signs/symptoms of dizziness the first time the client gets out of bed. After the client sits on the side of the bed, remind the client to stand on the unaffected leg.

The nurse is planning to get a client out of bed for the first time after having a total hip arthroplasty (THA). What specific actions would the nurse take? Select all that apply.

Insert the suppository 1 to 2 cm into the rectum.

The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action?

Do you have a history of seizures? Do you have a history of a clotting disorder How long and why have you been using ginkgo? Have you been diagnosed with diabetes mellitus?

While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate? Select all that apply.

Remove the gown from the client and remove the client from the room.

The nurse enters the room to find that the client's trash can is in flames. The client is in bed and the edge of the gown is smoking. The nurse should take which action first?

Keeping the bathroom light off at nighttime Placing the client in the quiet area of the nursing unit in a room away from the nurse's station

The nurse in the hospital is assisting in developing a plan of care for an older client to prevent a fall. Which actions would be least likely to prevent a fall? Select all that apply.

Promoting venous return to the heart

The nurse is assigned to assist in caring for a client who has had surgery and has pneumatic sequential compression devices (SCDs) in place. The client asks about these devices. The nurse instructs the client that SCDs are used for which purpose?

A pair of scissors

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

Testing stools and urine for blood Using a soft toothbrush for mouth care

The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000 mm3 (19 × 109/L).Based on this laboratory result, which actions should the nurse include in the plan of care? Select all that apply.

There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.

The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason?

Use a friction-reducing slide sheet. Use a mechanical lift to move the client. Keep elbows close and work close to the body. Obtain assistance of a second caregiver to assist with mechanical aids.

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply.

It helps to make sure that the primary health care provider is aware of all of the medications the client is taking and has been taking at home.

The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?

Blotting up the spill with a face cloth or cloth towel

The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill

Adequacy of circulation in the body area that is restrained Type of restraint and body area where the restraint was applied Communication with client and family member about need for restraint The alternative measures that were attempted before restraints were applied

The nurse initiates a prescription from the primary health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information should the nurse document in the client's medical record regarding restraints? Select all that apply.

Question the client about feelings of dizziness. Put the client's shoes on to help the client avoid slipping on the floor during the transfer Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions should the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply.

Disconnecting the IV tubing from the catheter in the vein

The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown?

The nurse should extend one leg to use to slide the client's body down to the floor.

The nurse is assisting a client to ambulate when the client states he is feeling faint and cannot stand. Which action should the nurse take to assist the client now?

Preoxygenating the client before suctioning Moistening the catheter tip in sterile saline solution before suctioning Introducing the catheter into the tracheostomy tube using a sterile gloved hand

The nurse is preparing to suction a client through a tracheostomy tube. The nurse should perform which actions when performing this procedure? Select all that apply.

I need to be sure to place my cup of coffee on the counter."

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

We will be sure not to leave hot liquids unattended."

The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?

Upright in a chair

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal how should the nurse position the client?

Clean towel, Sterile 10- or 12-mL syringe

The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment should the nurse obtain to perform this procedure? Select all that apply.

Alternating air pad

The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?

Admit the client to a private room.

The nurse is told that a client will be admitted to the hospital for a radiation implant. The nurse is asked to prepare for the admission of the client and plans which measure for this client?

Handgrips are positioned so the elbows are bent approximately 30 degrees. The space between the axilla and the top of the crutch pad is 1½ to 2 inches. The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.

The nurse determines that the client has a proper fitting of the crutches when which criteria have been fulfilled? Select all that apply.

Homeopathy Herbal supplements

The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse should be most concerned with the client who uses which CAMs? Select all that apply.

Explain the procedure to the client. Irrigate the NG tube with saline. Elevate the head of the bed to 45 degrees.

The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply.

"I will remove the ice pack if I start to feel numbness." "I should wrap the frozen ice pack in a towel to help adjust to the cold."

The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which client statements indicate adequate understanding of cold therapy treatment? Select all that apply

Wear gloves while administering the injected medication. Dispose of the needle and syringe in a puncture-resistant container.

The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome (AIDS) who requires an injection. The nurse should include which actions to safely administer the medication? Select all that apply.

Pedal pulses Capillary refill Color of the extremity Temperature of the skin Presence of numbness

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply.

Allowing the client sufficient time to eat, Providing oral hygiene after each meal, Maintaining a suction machine at the bedside

The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse should include which in the plan of care? Select all that apply.

Securing the oxygen tubing to the client's bottom sheet Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible

The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply.

Turn on the bed alarm Ask the client about needing to void or move bowels. Turn on the nightlight in the hospital room and bathroom

The nurse is caring for an older client who had surgery to repair a fractured hip. In the late evening the client becomes slightly confused and is moving about in bed. Which actions should the nurse take initially? Select all that apply

Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube.

The nurse is changing the neck ties on a tracheostomy tube. Which method is appropriate for the nurse to take?

Eat a nutritious diet with adequate protein. Use a pressure relief pad while in a wheelchair. Check the bottom sheet for wetness and wrinkles.

The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply.

Reset the degrees of flexion or extension according to comfort.

The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action?

"I need to refer to medication as 'candy' only when really necessary." "I can place several medications in the same bottle if I am going for an overnight trip."

The nurse is reinforcing instructions about home safety measures regarding medications and toxic substances to a parent. Which parent statements indicate a need for further teaching? Select all that apply.

Removing throw rugs and clutter in the home

The nurse is reinforcing instructions to a client with chronic vertigo that is poorly controlled. The nurse stresses the importance of which safety measure to prevent injury or exacerbation of symptoms?