Fundamentals Prep U Chapter 27 Safety, Security, and Emergency Preparedness

Systems around the documentation of prescriptions will be reviewed. The nurse will be found to have committed a human error.

A client's surgical wound dehisced when a nurse removed the staples before a health care provider prescription was given. Following root cause analysis, which organizational response is appropriate? Select all that apply. The nurse's actions will be deemed intentionally reckless. The nurse will be found to have committed a human error. Systems around the documentation of prescriptions will be reviewed. The nurse will be disciplined by an impartial review board. The nurse will be sued by the hospital for malpractice.

Obtain a three-prong grounded plug adapter.

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

"I am concerned that the small rugs in your home can be a tripping hazard."

A nurse visits an older adult client at home and assesses the safety of the client's environment. Multiple small rugs are located in the home. Which statement by the nurse is appropriate when addressing the client's safety? "Your home needs to be a safe environment as older adults have a tendency to fall." "I think you should replace your small rugs with skid-resistant rugs on the floor." "I am concerned that the small rugs in your home can be a tripping hazard." "You need to remove the small rugs from your house or you will fall."

Reduce the temperature on the water heater.

An older adult client has developed diabetic neuropathy. What would be the most important education intervention for the client and family? Obtain a carbon monoxide detector in the home. Reduce the temperature on the water heater. Keep the environment warmer in winter. Increase the amount of ventilation in the house.

mass trauma terrorism.

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. chemical terrorism. bioterrorism. nuclear terrorism.

Activate the fire alarm and notify the appropriate person.

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following? Activate the fire alarm and notify the appropriate person. Attempt to extinguish the fire. Alert the local fire department. Answer all telephone calls and call bells.

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.

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. Obtain order from a licensed provider within minutes of restraint application. Withhold information from family regarding restraints due to HIPAA. Check circulation and skin condition every 2 hours. Offer regular, frequent opportunities for toileting. Maintain restraints until discharge.

Extremity restraint

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure? Mummy restraint Elbow restraint Waist restraint Extremity restraint

Assess the need for assistance with ambulation.

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? Assess the need for assistance with ambulation. Put the client's bedside rails up. Apply socks to the client's feet. Arrange furniture so that the client has something to hold on to.

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

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? Risk for Falls related to immobility Risk for Injury related to substance use Risk for Poisoning related to poor eyesight and the inability to read medication labels Altered Sensory Perception related to decreased visual acuity

"At the age of 6 your child should be using a booster seat."

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? "Car seats are only recommended until children are 3 years old." "At the age of 6 your child should be using a booster seat." "Car seats are recommended until children are at least 10 years old." "Your child will be safe in the car using the provided shoulder harness and lap belts."

Refrain from using extension cords.

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? Leave outlets and switches open so air circulates through them. All machines that are used infrequently are to remain plugged in. Remove the plug from the wall by pulling the electric cord. Refrain from using extension cords.

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

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

"Is your child breathing at this time?"

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? "Did you leave the household chemical in reach of your child?" "Is your child breathing at this time?" "You should not have left your child alone while you showered." "Induce vomiting and call 911 right away."

Providing prompt recognition of the potential or actual threat to safety

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

A 70-year-old female with postural hypotension who wears eyeglasses

When performing fall risk assessments, which client does the nurse determine is most at risk for falls? A 50-year-old male being cared for in an unfamiliar health care environment A 60-year-old male with weakness in his left side and slowed reaction time A 70-year-old female with postural hypotension who wears eyeglasses An 80-year-old female with a history of falling last year

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.

A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply. Keep identifying information posted on the web sites. Use filtering software to block objectionable information. Investigate any public chat rooms used by the children. Emphasize that everything read online is usually true. Be alert for downloaded files with suffixes that indicate images or pictures.

Risk for Poisoning related to medications in unlocked cabinets

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 Contamination related to flaking or peeling of paint Risk for Injury related to substance use Risk for Poisoning related to medications in unlocked cabinets Risk for Suffocation related to child left unattended in the bathtub

A toddler allowed to crawl in a house that has not been childproofed An older adult client with a shuffling gait

The nurse is evaluating risk factors for a developmentally diverse group of clients. Which client(s) is at risk for safety? Select all that apply. A toddler allowed to crawl in a house that has not been childproofed A machinist working in an environment with exposure to loud noises A sales executive worried about making the yearly sales quota An older adult client with a shuffling gait A 42-year-old client with left-side paralysis following a stroke

Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with. Use three-pronged electric plugs whenever possible.

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply. Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with. Use three-pronged electric plugs whenever possible. Twist or bend electric cords to make sure the cords are not dragging on the floor. Clean all equipment with soap and water after use.

Ensure that two fingers can be inserted between the restraint and the client's extremity.

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? Apply restraints to the hands or wrists, never to the ankles. Ensure that two fingers can be inserted between the restraint and the client's extremity. Use a quick-release knot to tie the restraint to the side rail. Remove the restraint at least every 4 hours, or according to facility policy.

Provide a bedside commode and ensure adequate lighting.

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

Reduce distressing environmental stimuli to maximize client safety

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

Peer pressure causes children of this age to take risks.

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

Remove the client from the room.

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action? Remove the client from the room. Obtain the fire extinguisher. Activate the fire alarm. Close the client's door.

Flush the eyes with water for 10 minutes.

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? Wash the eyes with a hypertonic solution for at least 30 minutes. Advise the client to avoid blinking until after the eyes are irrigated. Flush the eyes with water for 10 minutes. Flush the eyes with a cool saline solution for a 10-minute period.

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

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 reinforcing the standards for nursing care to staff members who were involved ensuring that the client's nurse is held accountable and educated about best practice communicating the potential consequences of the near miss to the client involved

a rocking horse

A nurse is caring for an 18-month-old client after a tracheostomy. The client 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 beaded bracelet dominos a rocking horse marbles

Insert a fist between the restraint and the client to ensure that her breathing is not constricted.

An order for a waist restraint has been obtained for a client who is a threat to her own safety. The nurse should perform which action? Place the client in a prone position to apply the restraint. Remove the client's upper body clothing and reapply it over the restraint. Insert a fist between the restraint and the client to ensure that her breathing is not constricted. Assess the client at least every 2 hours or according to facility policy, as required.

19-year-old male college student majoring in physics

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 25-year-old female who just accepted her first job 34-year-old male who does not use a seat belt 40-year-old female who is working two jobs

The importance of wearing a helmet

The home care nurse observes that a child is learning to ride a bicycle. Which would the nurse teach the child about bicycle safety? The importance of wearing a helmet The importance of using wrist guards The importance of wearing knee pads The importance of using the buddy system

Risk for Injury Related to Agitation

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

Assess for the need to urinate.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate? Assess for the need to urinate. Administer a prescribed dose of lorazepam. Raise the side rails. Contact the health care provider for a prescription to apply a waist restraint.

A nurse who has worked 32 hours of overtime this week

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 who has placed a client in the bed with three side rails up A nurse who is transferred to another unit to assist with care A nurse who is administering medications to four clients

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

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: complete an incident report to determine who was primarily responsible for the event. document strategies in the client's health record for preventing future incidents. fill out an incident report, with the goal of preventing a similar event in the future. hold a facility-wide meeting to identify strategies for making improvements to the safety of residents.

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

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? The hospital must bear any costs incurred for treating the client's injury. The hospital will be fined by CMS because the client developed a pressure injury. CMS will bear the hospital's costs if the client chooses to sue the hospital. CMS may choose to divert clients to other health care facilities in the future.

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

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

The nurse should make a copy of the safety event report and place it in the client's medical record.

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 researches best current practices for prevention of the spread of infection in physician offices.

A nurse is using the QSEN competency of evidence-based practice when caring for clients. What is an example of this competency? The nurse works with other health care team members to provide care for a client diagnosed with Alzheimer's disease. The nurse manager holds an in-service for staff to teach them the safe operation of a new piece of equipment. The nurse researches best current practices for prevention of the spread of infection in physician offices. The nurse uses computer-generated care plans for client care.

Pull the fire alarm lever.

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? Evacuate the unit. Pull the fire alarm lever. Confine the fire. Extinguish the fire.

a dose of an antipsychotic

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 side rails a geriatric chair with a tray a dose of an analgesic

Initiate use of a bed alarm.

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