Fundamentals of Success Safety

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10. Which should the nurse do to best prevent a patient from falling? 1. Provide a cane. 2. Keep walkways clear of obstacles. 3. Assist the patient with ambulation. 4. Encourage the patient to use hallway handrails.

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11. Which is the last step in making an occupied bed that the nurse should teach a nursing assistant? 1. Elevating the head of the bed to a semi-Fowler position 2. Ensuring that the patient is in a comfortable position 3. Lowering the height of the bed toward the floor 4. Raising both the side rails on the bed

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12. The nurse is caring for a patient with a nasogastric tube for gastric decompression. Which nursing action takes priority? 1. Discontinuing the wall suction when providing care 2. Positioning the patient in the semi-Fowler position 3.Instilling the tube with 30mL of air every 2 hours 4.Caring for the nares at least every 8 hrs.

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13. A patient states that when turning on an electric radio a strong electrical shock was felt. What should the nurse do first? 1.Arrange for the maintenance department to examine the radio 2.Disconnect the radio from the source of energy 3.Check the skin for electrical burns 4. Take the patient's apical pulse

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14. A nurse educator is teaching a group of newly hired nursing assistants. Which patient should they be taught is at the greatest risk for injury? 1. School-aged children 2. Comatose teenager 3. Postmenopausal woman 4. Confused middle-aged man

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15. A nurse in the nursing education department of a community hospital is planning an in service education class about injury prevention. Which factor that most commonly causes physical injuries in hospitalized patients should be included in the teaching plan? 1. Malfunctioning equipment 2. Failure to use restraints 3. Visitors 4. Fall

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16. Which is the priority nursing intervention to prevent patient problems associated with latex allergies? 1.Use nonlatex gloves 2.Identify persons at risk 3.Keep a latex-safe supply cart available 4. Administer an antihistamine prophylactically

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17. Which nursing intervention enhances an older adult's sensory perception and thereby helps prevent injury when walking from the bed to the bathroom? 1. Providing adequate lighting 2. Raising the pitch of the voice 3. Holding onto the patient's arm 4. Removing environmental hazards

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18. A nurse is preparing a patient for a physical examination. What is most important for the nurse to do in this situation? 1.Identify the positions that may be contraindicated for the patient during the examination 2.Explore the patient's attitude toward health-care providers 3.Inquire about the other professionals caring for the patient 4.Ask when the patient last had a physical examination

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19. A patient has dysphagia. Which nursing action takes priority when feeding this patient? 1. Ensuring that dentures are in place 2.Medicating for pain before providing meals 3.Providing verbal cueing to swallow each bite 4.Checking the mouth for emptying between every bite

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2. A nurse is caring for a patient with Parkinson's disease who is experiencing difficulty swallowing. What potential problem associated with dysphagia has the greatest influence on the plan of care? 1.Anorexia 2.Aspiration 3.Self-care deficit 4. Inadequate intake

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20. A 3 year old child is admitted to the pediatric unit. What is the best way for the nurse to maintain the safety of this preschool-age child? 1.Teaching the child how to use the call bell 2.Placing the child in a crib with high side rails 3.Keeping the child under constant supervision 4.Having the child stay in the playroom most of the day

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21. Which time of day is of most concern for the nurse when trying to protect a patient with dementia from injury? 1. Afternoon 2. Morning 3. Evening 4. Night

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22. A nurse is orienting a newly admitted patient to the hospital. Which is most important for the nurse to teach the patient how to do? 1. Notify the nurse when help is needed. 2. Get out of the bed to use the bathroom. 3. Raise and lower the head and foot of the bed. 4. Use the telephone system to call family members.

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24. Profuse smoke is coming out of the heating unit in a patient's room. What should the nurse do first? 1.Open the window 2.Activate the fire alarm 3.Move the patient out of the room 4.Close the door to the patient's room

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24. The nurse must apply a hospital gown that does not have snaps on the shoulders to a patient receiving an intravenous infusion in the forearm.What should the nurse do? 1.Insert IV bag and tubing through the sleeve from inside of the gown first 2.Disconnect the IV at the insertion site, apply the gown, and then reconnect the IV 3. Close the clamp on the IV tubing no more than 15 seconds while putting on the gown 4.Don the gown on the arm without the IV, drape the gown over the other shoulder and adjust the closure behind the neck

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25. The nurse is planning care for a patient with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range? 1.Once a shift 2.Once an hour 3.Every 2 hours 4.Every 4 hours

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26. Which is the first action the home-care nurse should employ to prevent falls by an older adult living at home? 1. Conduct a comprehensive risk assessment. 2. Encourage the patient to remove throw rugs in the home. 3. Suggest installation of adequate lighting throughout the home. 4. Discuss with the patient the expected changes of aging that place one at risk

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27. A nurse is preparing a bed to receive a newly admitted patient. Which action is most important? 1. Placing the patient's name on the end of the bed 2. Ensuring that the bed wheels are locked 3. Positioning the call bell in reach 4. Raising one side rail

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28. Which are appropriately worded goals for a patient who is at risk for falling? Select all that apply. 1. _____ "The patient will be able to walk from a bed to a chair safely while hospitalized." 2. _____" The patient will be taught how to call for help to ambulate." 3. _____" The patient will be kept on bedrest when dizzy." 4. _____" The patient will be restrained when agitated." 5. _____" The patient will be free from trauma."

an X where the mitt restraint strap should be secured with a quick-release knot.

29.

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3. A. nurse is caring for a confused patient. What should the nurse do to prevent this patient from falling? 1.Encourage the patient to use the corridor handrails 2. Place the patient in a room near the nurses' station 3.Reinforce how to use the call bell 4.Maintain close supervision

2, 4, 5

30. Which interventions should a nurse implement when assisting a patient to use a bedpan? Select all that apply. 1. _____Du st powder on the rim before placing the bedpan under the patient. 2. _____Ensure that the bed rails are raised once the patient is on the bedpan. 3. _____Position the rounded rim of the bedpan toward the front of the patient. 4. _____Encourage the patient to help as much as possible when using the bedpan. 5. _____Raise to the semi-Fowler position once the patient is placed on the bedpan

1, 3, 2, 4

31. A nurse identifies the presence of smoke exiting the door to the dirty utility room. Place the nurse's actions in order of priority using the RACE model. 1. Pull the fire alarm. 2. Close unit doors and windows. 3. Shut the door to the utility room. 4. Provide emotional support to agitated patients. Answer: _______________

1, 4, 6

32. Which clinical manifestation indicates that a further nursing assessment is necessary to determine if the patient is having difficulty swallowing? Select all that apply. 1. _____Debris in the buccal cavity 2. _____Abdominal cramping 3. _____Epigastric pain 4. _____Slurred speech 5. _____Constipation 6. _____Drooling

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33. A male patient is admitted to ambulatory care for a bilateral herniorrhaphy. A nurse on the unit interviews the patient, obtains the patient's vital signs, and reviews the primary health-care provider's orders. Which should the nurse do first ? 1. Contact the operating suite and inform them of the patient's latex allergy. 2. Ensure the patient's allergy band includes the patient's identified allergies. 3. Notify the primary health-care provider of the patient's elevated vital signs. 4. Share the information about the patient's anxiety with health team members.

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34. A nurse is planning care for a patient who requires bilateral arm restraints because the patient is delirious and attempting to pull out a urinary retention catheter. Which information is important to consider when planning care for this patient? Select all that apply. 1. _____Use of restraints adequately prevents injuries. 2. _____Reasons for use of restraints must be clearly documented. 3. _____Most patients recognize that restraints contribute to their safety. 4. _____Restraints need a primary health-care provider order before application. 5. _____Laws permit the use of restraints when specific guidelines are followed.

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35. A nurse is implementing the action demonstrated in the illustration. Which is the nurse doing? 1. Transferring a patient into a wheelchair 2. Teaching abdominal breathing to a patient 3. Dislodging an object from a patient's airway 4. Holding a patient up after the patient became dizzy when walking

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36. An adult patient consistently tries to pull out a urinary retention catheter. As a last resort to maintain integrity of the catheter and patient safety, the nurse obtains an order for a restraint. Which types of restraints are most appropriate in this situation? Select all that apply. 1. _____Mummy restraint 2. _____Elbow restraint 3. _____ Jacket restraint 4. _____Wrist restraint 5. _____Mitt restraint

4, 5, 2, 3, 1

37. A nurse uses the Get Up and Go test to assess a patient for weakness, poor balance, and decreased flexibility. Place the following actions in the order in which they should be implemented when employing the Get Up and Go test. 1. Ask the patient to walk 10 feet and then to return to the chair. 2. Ask the patient to close the eyes. 3. Ask the patient to open the eyes. 4. Ask the patient to sit in a chair. 5. Ask the patient to stand.

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38. Which actions are important when the nurse uses a stretcher? Select all that apply. 1. _____ Lowering the bed below the level of the stretcher when transferring a patient from the stretcher to a bed 2. _____ Guiding the stretcher around a turn leading with the end with the patient's head 3. _____Ensuring the patient's head is at the end with the swivel wheels 4. _____Pulling the stretcher on the elevator with the patient's feet first 5. _____Pushing the stretcher from the end with the patient's head

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39. Which human responses to illness alert the nurse that a patient is at risk for aspiration during meals? Select all that apply. 1. _____Bulimia 2. _____Lethargy 3. _____Anorexia 4. _____Stomatitis 5. _____Dysphagia

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4. A school nurse is teaching children about fire safety procedures. What is the first thing they should be taught to do if their clothes catch fire? 1. Yell for help 2.Roll on the ground 3.Take their clothes off 4.Pour water on their clothes

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40. A nurse is caring for a patient with a moderate problem with balance. Place an X over the cane that is most appropriate for this patient.

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5. A primary health-care provider orders a vest restraint for a patient. Which should the nurse do first when applying this restraint? 1. Perform an inspection of the patient's skin where the restraint is to be placed. 2. Ensure that the back of the vest is positioned on the patient's back. 3. Permit four fingers to slide between the patient and the restraint. 4. Secure the restraint to the bed frame using a slipknot.

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9. A nurse is assessing a patient who is being admitted to the hospital. Which is the most important information that indicates whether the patient is at risk for physical injury? 1. Weakness experienced during a prior admission 2. Medication that increases intestinal motility 3. Two recent falls that occurred at home 4. The need for corrective eyeglasses

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A toaster is on fire in the pantry of a hospital unit. What should the nurse do first? 1.Unplug the toaster 2.Activate the fire alarm 3.Put out the fire with an extinguisher 4.Evacuate the patients from the room next to the kitchen

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1. A resident brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. What rationale should the nurse provide when explaining why an electrical device must have a three pronged plug? 1. Controls stray electrical currents 2. Promotes efficient use of electricity 3. Shuts off the appliance if there is an electrical surge 4. Divides the electricity among the appliances in the room.

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An unconscious patient begins to vomiting. In what position should the nurse place the patient? 1. Supine 2. Side lying 3. Orthopneic 4. Low Fowler

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The risk management coordinator is preparing a program on the factors that contribute to falls in a hospital setting. Which factor that most often contributes to falls should be included in the program? 1. Wet floors 2.Frequent seizures 3.Advanced age of patients 4.Misuse of equipment by nurses