Fundamentals of Nursing Ch. 32

The nurse is installing a bed safety-monitoring device for a client. What should the nurse do after testing the device and alarm sound? 1. Place the leg band on the client with the leg in a straight horizontal position. 2. Place the sensor under the mattress near the shoulder region. 3. Set a time delay for 30 seconds. 4. Connect the sensor pad to the control unit.

Correct Answer: 1 Rationale 1: After testing the device and alarm sound, the nurse should place the leg band on the client with the leg in a straight horizontal position. Rationale 2: The sensor should be placed under the mattress at the buttocks area, not the shoulder area. Rationale 3: Time delays should be between 1 and 12 seconds. Rationale 4: Connecting the sensor pad to the control unit is the last step when installing the bed safety-monitoring device.

The nurse is reviewing safety with a home-care client. What should the nurse include in this teaching? 1. Always pull a plug at the plug-in from the wall outlet. 2. Keep plants in the home. 3. Use overloaded outlets when necessary. 4. Remove labels from containers and refill for recycling.

Correct Answer: 1 Rationale 1: Always pull a plug at the plug-in from the wall outlet. Pulling a plug by its cord can damage the cord and plug unit, creating a dangerous situation. Rationale 2: Not knowing which plants are poisonous and which are not may pose a serious problem for children in the home. Rationale 3: Always avoid overloading outlets at any time because this can cause a fire. Rationale 4: Do not remove container labels or reuse empty containers to store different substances. Laws mandate that the labels of all substances specify an antidote.

The nurse is planning care for an older client. Which safety hazard should the nurse take into consideration when planning this care? 1. Burns 2. Drowning 3. Poisoning 4. Suffocation

Correct Answer: 1 Rationale 1: Falls, burns, and pedestrian and motor vehicle crashes are safety hazards in older adults. Rationale 2: Drowning and poisoning are seen in the toddler-age client. Rationale 3: Drowning and poisoning are seen in the toddler-age client. Rationale 4: Suffocation is a hazard in newborns and infants.

While eating in a restaurant, a nurse notices that a customer at the next table begins to clutch his throat while eating a steak. What should the nurse do first? 1. Ask the customer if he is choking. 2. Attempt to give five back blows. 3. Perform the Heimlich maneuver. 4. Start chest compressions.

Correct Answer: 1 Rationale 1: The first step is to ask if the person is choking. Rationale 2: Five back blows are reserved for an infant who is choking. Rationale 3: If he indicates he is choking, the next step would be to perform the Heimlich maneuver. Rationale 4: Chest compressions would be given if the person was unconscious; this person is not. He is clutching his throat.

The nurse is evaluating teaching provided to a client about home safety. Which observation indicates that teaching has been effective? 1. Smoke alarm functioning with new batteries installed 2. Scatter rugs located in the kitchen and bathroom only 3. Cord for a space heater stretched across a hallway 4. Light bulbs burned out in the bathroom and living room

Correct Answer: 1 Rationale 1: The installation and use of a smoke alarm in the home would indicate that home safety instruction has been effective. Rationale 2: Scatter rugs would indicate that instruction on home safety has not been effective. Rationale 3: Cords for appliances stretching across major walkways would indicate that instruction on home safety has not been effective. Rationale 4: Inadequate lighting in major rooms of the home would indicate that instruction on home safety has not been effective.

A client is prescribed seizure precautions. The nurse places functioning oral suction equipment in the clients room for what reason? 1. Suctioning might be needed to prevent the aspiration of oral secretions. 2. The client has difficulty swallowing liquids. 3. There was a spare oral suction set up, and the nurse did not want to return it to the engineering department. 4. It helps when the client is brushing her teeth.

Correct Answer: 1 Rationale 1: When implementing seizure precautions, the nurse should place oral suction equipment in the clients room because suctioning might be needed to prevent aspiration of oral secretions. Rationale 2: If the client were having difficulty swallowing liquids, oral suction already would be in the clients room. Rationale 3: Placing a piece of equipment in a clients room that is not needed is not a good utilization of resources. Rationale 4: Having oral suction equipment available for teeth brushing is not the best use of the equipment.

An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait. What should the nurse assess in this client to promote home safety? Standard Text: Select all that apply. 1. Presence of grab bars in the bathroom 2. Absence of scatter rugs on the floors 3. Correct use of cane to ambulate 4. Ability to stand in place for a minute before ambulating 5. Alcohol use with prescribed medications

Correct Answer: 1, 2, 3 Rationale 1: For home safety, it would be beneficial for the client with difficulty moving from a sitting to standing position to have grab bars in the bathroom. Rationale 2: For home safety, it would be beneficial for the client with an unsteady gait not to have scatter rugs on the floor. Rationale 3: For home safety, it would be beneficial for the client with an unsteady gait to be able to use a cane correctly. Rationale 4: The ability to stand in place for a minute before ambulating would be applicable if the client were demonstrating signs of orthostatic hypotension. Rationale 5: The use of alcohol with prescribed medications would be beneficial if the client were prescribed sedatives or hypnotics.

A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints. Standard Text: Click and drag the options below to move them up or down. Choice 1. Pad bony prominences on the wrist. Choice 2. Apply the padded portion of the restraint around the wrist. Choice 3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. Choice 4. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.

Correct Answer: 1, 2, 3, 4 Rationale 1: Prior to applying the wrist restraint, the clients bony prominences should be padded. Rationale 2: The nurse should apply the padded portion of the restraint around the wrist. Rationale 3: The nurse should then pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. Rationale 4: The nurse should then attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.

The nurse is determining a clients risk for injury. What should the nurse assess in this client? Standard Text: Select all that apply. 1. Age 2. Mobility 3. Hearing 4. Vision 5. Dietary intake

Correct Answer: 1, 2, 3, 4 Rationale 1: The ability of a person to protect him- or herself from injury is dependent upon age. Rationale 2: The ability of a person to protect him- or herself from injury is dependent upon mobility. Rationale 3: The ability of a person to protect him- or herself from injury is dependent upon hearing. Rationale 4: The ability of a person to protect him- or herself from injury is dependent upon vision. Rationale 5: The ability of a person to protect him- or herself from injury is not dependent upon dietary intake

During a home visit, the nurse determines that a toddler is at risk for injury. What did the nurse assess to identify this clients risk? Standard Text: Select all that apply. 1. Unscreened windows 2. Electrical outlets uncovered 3. Yard with a built-in pool unfenced 4. Cleaning solution in the bottom cabinet 5. Pots on stove with handles turned inward

Correct Answer: 1, 2, 3, 4 Rationale 1: Unscreened windows would be a safety hazard for a toddler. Rationale 2: Uncovered electrical outlets would be a safety hazard for a toddler. Rationale 3: Having a backyard pool without a fence is a safety hazard for a toddler. Rationale 4: Cleaning solution in the bottom cabinet can be easily reached by a toddler, creating a safety hazard. Rationale 5: Pots on stove with the handles turned inward is the appropriate way to maintain safety in a home with a toddler.

The nurse is appointed to be a member of committee whose focus is to identify and address workplace safety issues. Which issues should the nurse recommend for analysis by this committee? Standard Text: Select all that apply. 1. Lifting clients 2. Inadequate lighting 3. Bending and walking 4. Exposure to infectious agents 5. Exposure to hazardous medications

Correct Answer: 1, 3, 4, 5 Rationale 1: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include lifting. Rationale 2: Inadequate lighting would be a safety issue in a home or community neighborhood. Rationale 3: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include bending and walking. Rationale 4: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include exposure to infectious agents. Rationale 5: The U.S. Bureau of Labor Statistics (2012) reports that nursing has many hazards. Some of the hazards include exposure to hazardous compounds.

The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. What should the nurse advise the mother to do? 1. Omit the afternoon nap. 2. Place a crib net over the top of the crib. 3. Remove all objects from around the crib. 4. Restrain the child if he gets up more than once.

Correct Answer: 2 Rationale 1: A child of 2 years should still be taking a nap, and that poses a dangerous situation, at naptime or bedtime, if the child is still crawling out of the crib. Rationale 2: A crib net will prevent an active child from climbing out of the crib but will allow him freedom to move about in the crib. Rationale 3: Just removing objects off the floor from around the crib would not prevent a child from climbing out of a crib. Rationale 4: Restraining the child would be dangerous and contribute even more to his determination of getting out of the crib.

The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client? 1. Assign this client to the farthest room from the nurses station. 2. Place a rocking chair in the clients room. 3. Pull up all of the side rails on the bed. 4. Wedge pillows against the side rails on the bed.

Correct Answer: 2 Rationale 1: Assigning the client to the farthest room from the nurses station would be an unsafe move for the client; closer would be safer than farther. Rationale 2: Placing a rocking chair in the clients room will help her to expend some of her energy so that she will be less inclined to walk and wander. Rationale 3: Pulling up all of the side rails is a restraint, so that action would not be an alternative. Rationale 4: Keeping pillows wedged against the side rails will not keep the client from wandering. She is not in the bed.

The nurse is planning care for a client who is prone to falling. Which nursing diagnoses should the nurse use for this client? 1. Deficient Knowledge 2. Risk for Injury 3. Risk for Disuse Syndrome 4. Risk for Suffocation

Correct Answer: 2 Rationale 1: Deficient Knowledge deals with injury prevention. A client who is already prone to falls may not have the cognitive ability for a knowledge deficient. Rationale 2: Risk for Injury is a state in which the individual is at risk as a result of environmental conditions such as a fall. Rationale 3: Risk for Disuse Syndrome is a deterioration of body system as the result of prescribed or unavoidable musculoskeletal inactivity. Rationale 4: Risk for Suffocation is inadequate air available for inhalation.

An older client diagnosed with Alzheimers disease continually tries to get out of bed at night. Which safety measure should the nurse consider using with this client? 1. Explain all procedures and treatments. 2. Place a bed safety monitoring device on the bed. 3. Orient the client to surroundings. 4. Use relaxation techniques.

Correct Answer: 2 Rationale 1: Explaining procedures would not be appropriate with this client. Rationale 2: Alzheimers disease causes impaired intellectual functioning, so a safety device that is weight sensitive would alert the nurse when the client is trying to get out of bed. Rationale 3: Orienting to surroundings would not be appropriate with this client. Rationale 4: Using relaxation techniques would not be appropriate with this client.

While the nurse is performing morning care, a client begins to have a seizure. What should the nurse do to help this client? 1. Insert a tongue blade into the clients mouth. 2. Loosen any clothing around the neck and chest. 3. Restrain the client. 4. Turn the client to the supine position if possible

Correct Answer: 2 Rationale 1: Research has found that more injury can occur to the client if the caregiver tries to place anything in the mouth during the seizure. Rationale 2: Loosening any clothing around the neck and chest prevents constriction that might occur during the seizure that could compromise the airway. Rationale 3: A client should never be restrained during a seizure. The nurse should stay with the client and call for assistance, if needed. Rationale 4: If possible, the client should be turned to the lateral position, not supine, to allow for any secretions to drain out of the mouth.

The nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client? 1. Client wanders around the care area. 2. Client is picking at the access site for intravenous infusion of chemotherapy. 3. Client needed to use the bathroom and waited for help but didnt want to soil the bed and fell while attempting to walk to the bathroom. 4. Client does not want to stay in bed but wants to sit in the lounge with others.

Correct Answer: 2 Rationale 1: Restraints cannot be used for the convenience of the care staff. Rationale 2: In this situation, the clients actions could hinder his or her health status and a restraint would be indicated. Rationale 3: This situation would not call for the client to be restrained. The care staff needs to be more attentive to the clients needs. Rationale 4: This client would not be a candidate for restraints.

The nurse is identifying outcomes for an older client prone to injuries. Which outcome should the nurse identify as appropriate for this client? 1. The client will demonstrate an understanding of all limitations. 2. The client will establish a buddy system. 3. The client will make uninformed choices when addressing health issues. 4. The client will take his medication as desired.

Correct Answer: 2 Rationale 1: The client may resent limitations and act out in such a way as to cause injury. Rationale 2: Establishing a buddy system provides social contact, safeguards against abuse, and offers respite for caregivers. It also provides a way for elders to be checked up on daily. Rationale 3: Making uninformed choices about ones health would be unsafe instead of safe for the client. Rationale 4: A routine should be established for medication administration with correct dosage to prevent the possibility of overdose toxicity.

The nurse is applying restraints to a client. After securing a health care providers order, what should the nurse do? 1. Assess the restraints every 10 minutes. 2. Pad bony prominences. 3. Secure the restraint to the side rail. 4. Tie the restraint with a square knot.

Correct Answer: 2 Rationale 1: The restraints should be assessed according to agency policy but no less frequently than every 2 hours. Rationale 2: Padding bony prominences will prevent possible skin breakdown. Rationale 3: Restraints are never tied to a side rail. The ends should be secured to the part of the bed that moves to elevate the head. Rationale 4: When a restraint is secured in place, a clove-hitch knot should be used, not a square knot. The clove-hitch knot will not tighten when pulled.

A client is prescribed seizure precautions. What can the nurse safely delegate to UAP to complete when implementing the precautions? 1. Placing a tongue blade at the head of the bed 2. Padding the clients bed 3. Installing oxygen 4. Checking the oral suction apparatus

Correct Answer: 2 Rationale 1: Tongue blades are not used as part of seizure precautions, and should not be placed at the head of the bed. Rationale 2: The nurse can safely delegate the padding of the bed to UAP. Rationale 3: The nurse should install the oxygen. Rationale 4: The nurse should check the oral suction apparatus.

The home care nurse wants to ensure the safety of an older client who lives at home alone. Which intervention should the nurse identify as a way to prevent this client from falling? 1. Check vision every 5 years. 2. Exercise regularly. 3. Place socks on feet. 4. Turn the light on after getting out of bed.

Correct Answer: 2 Rationale 1: Vision can be a cause of falls, but it should be checked at least once a year; every 5 years is not often enough. Rationale 2: The client needs to exercise regularly to maintain strength, flexibility, mobility, and balance, which prevents falls. Rationale 3: Older clients should have something on their feet when walking, but not socks that will allow them to fall. A nonskid-type sock or shoe will help prevent falls. Rationale 4: The client should be able to turn the light on before getting out of bed, as inadequate lighting is another cause for falls.

A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this clients documentation? Standard Text: Select all that apply. 1. Who assisted the client back to bed 2. Location of the seizure 3. Duration of the seizure 4. Status of airway and use of oxygen 5. Who discovered the client

Correct Answer: 2, 3, 4 Rationale 1: It is not important for the nurse to name the individuals who assisted the client back to bed. Rationale 2: Documentation should include where the client was when the seizure occurred. Rationale 3: Documentation should include the duration of the seizure. Rationale 4: Documentation should include the status of the clients airway and use of oxygen. Rationale 5: It is not important for the nurse to name the individual who found the client having a seizure.

The nurse would like to improve communication among caregivers. How should the nurse use the Joint Commission 2013 National Patient Safety Goals to achieve this objective? 1. Review a list of look-alike/sound-alike drugs used in the organization. 2. Use a verification process to confirm the correct procedure. 3. Report critical results of tests and diagnostic procedures on a timely basis.. 4. Use the clients room number as an identifier.

Correct Answer: 3 Rationale 1: Annually reviewing a list of look-alike/sound-alike drugs is used to improve the safety of use of medication in an organization, not to improve communication. Rationale 2: Using a verification process to confirm that the correct procedure for the correct client is to be performed is another way to improve the accuracy of client identification. Rationale 3: Reporting critical results of tests and diagnostic procedures on a timely basis is one way the National Patient Safety Goals improve the communication among caregivers. Rationale 4: Using the clients room number as an identifier is a passive technique that would improve the accuracy of client identification.

As a member of the safety committee, the nurses task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls? 1. Display the phone number to the nurses station. 2. Keep electrical cords under the bed. 3. Keep the environment tidy. 4. Read label directions.

Correct Answer: 3 Rationale 1: Displaying the phone number to the nurses station is a way to call for help. Rationale 2: Electrical cords should only be used if necessary, and the maintenance department can help if any of them present a hazard. Rationale 3: Keeping the environment tidy and free of clutter will go a long way in preventing falls. Rationale 4: Reading label directions will prevent the wrong use of substances given to the client, but would not directly prevent falls.

The nurse is identifying activities and skills to delegate to unlicensed assistive personnel (UAP). Which action can the nurse safely delegate? 1. Provide oral fluids to a newly extubated client. 2. Irrigate the indwelling urinary catheter of a client recovering from prostate surgery. 3. Apply a wrist restraint to a client. 4. Administer oral pain medication to a client before the client attends physical therapy.

Correct Answer: 3 Rationale 1: Providing oral fluid to a newly extubated client should be done first by the nurse, so the client can be assessed for ability to safely swallow. Rationale 2: Irrigating an indwelling urinary catheter is beyond the scope for UAP. Rationale 3: Application of ordered restraints and their temporary removal for skin monitoring and care may be delegated to UAP who have been trained in their use. Rationale 4: Administering medication is beyond the scope for UAP.

The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for the client? 1. Keep clutter to a minimum in the clients room. 2. Have the client wear terry-cloth slippers. 3. Provide adequate lighting. 4. Turn off alarms to reduce noise.

Correct Answer: 3 Rationale 1: The environment should be clutter-free because any clutter can cause the client to fall. Rationale 2: Wearing terry-cloth slippers would allow the client to fall. The client should have rubber skid-resistant soles. Rationale 3: Providing adequate lighting will help prevent the client from falling. Rationale 4: Noise should be kept to a minimum, but turning off alarms would endanger a client.

The nurse is preparing to assess a client who has a history of falls. Which methods should the nurse use to assess this clients risk for injury? Standard Text: Select all that apply. 1. Cognitive awareness 2. Mobility 3. Nursing history 4. Physical examination 5. Health status

Correct Answer: 3, 4 Rationale 1: Cognitive awareness, mobility, and health status are factors affecting safety. Rationale 2: Cognitive awareness, mobility, and health status are factors affecting safety. Rationale 3: A nursing history and physical examination are methods to assess a client at risk for injury. Rationale 4: A nursing history and physical examination are methods to assess a client at risk for injury. Rationale 5: Cognitive awareness, mobility, and health status are factors affecting safety.

The nurse is reviewing safety hazards with a pregnant client. What should the nurse include when instructing this client about safety and the developing fetus? 1. Banging into objects 2. Bicycle rides 3. Recreational activities 4. X-rays

Correct Answer: 4 Rationale 1: Banging into objects is what a toddler would be likely to do, not an expectant mother. Rationale 2: Bicycle rides and recreational activities would be good for the developing fetus; the mother should stay as active as possible during the pregnancy. Physical activity promotes good health. Rationale 3: Physical activity promotes good health. Rationale 4: Exposure to x-rays in the first trimester could cause harm to the developing fetus.

The nurse is attending a seminar on bioterrorism. What should the nurse identify as being the highest concern for homeland security? 1. Cancer 2. Seasonal flu 3. Tuberculosis 4. Smallpox

Correct Answer: 4 Rationale 1: Cancer does not pose a threat to homeland security. Rationale 2: Seasonal flu does not pose a threat to homeland security. Rationale 3: Tuberculosis does not pose a threat to homeland security. Rationale 4: Smallpox, anthrax, botulism, plague, viral hemorrhagic fevers, and tularemia are the agents that are of highest concern with bioterrorism.

The nurse is preparing materials to instruct the parents of a newborn. What should the nurse identify as a safety hazard in an infant? 1. Exposure to alcohol consumption 2. Drowning 3. Pedestrian accidents 4. Suffocation in the crib

Correct Answer: 4 Rationale 1: Exposure to alcohol consumption is a safety hazard to a fetus. Rationale 2: Drowning is a safety hazard in toddlers and preschoolers. Rationale 3: Pedestrian accidents are safety hazards in the older adult. Rationale 4: Suffocation in the crib is a safety hazard for both newborns and infants

After ambulating a client to the bathroom, the unlicensed assistive personnel did not reattach the clients bed safety-monitoring device, and the client fell out of bed. What should the nurse document? 1. Client fell out of bed; bed safety-monitoring device malfunctioning. 2. Client fell out of bed; client removed leg band of bed safety-monitoring device. 3. Client fell out of bed; no observable injuries. 4. Client fell out of bed; bed safety-monitoring device not activated.

Correct Answer: 4 Rationale 1: The bed safety device was not activated. It was not malfunctioning. Rationale 2: The client did not remove the leg band of the monitoring device. Rationale 3: The nurse needs to report the fall to the primary care physician. Rationale 4: The nurse needs to document what occurred with the client and why.

A client is being transferred from an acute care facility to a long-term care facility. What information should the nurse provide to the long-term care facility about the clients medications? 1. Nothing, as the medications all need to be reordered at the long-term care facility. 2. Have the clients medication prescriptions filled before going to long-term care facility. 3. Instruct the client to tell the nurses at the long-term care facility what medications are prescribed. 4. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

Correct Answer: 4 Rationale 1: The nurse is responsible for communicating the clients medications to the long-term care facility, and documents this communication. Rationale 2: The clients medications will not be filled prior to going to the long-term care facility. Rationale 3: It is not the clients responsibility to communicate medications to the nurses at the long-term care facility. Rationale 4: The nurse should communicate the clients medications to the nurses at the long-term care facility and document that this communication occurred.

The nurse is identifying care goals for a client who is prone to getting hurt. Which care goal should the nurse select for this client? 1. Assess the clients mental status. 2. Keep the client dependent on the staff for all care. 3. Make all choices for the client. 4. Remain free from injury.

Correct Answer: 4 Rationale 1: The nurse will need to assess the clients mental status to help accomplish this goal. Rationale 2: Keeping the client dependent on the staff for care does not encourage independence. Rationale 3: Making all choices for the client does not encourage independence. Rationale 4: The major goal for a client who is at risk for injury is for the client to remain injury-free.