NRSG. CH. 27- Skills - Patient Safety

Which questions if asked by the nurse are useful for evaluating a patient's perception of safety? Select all that apply.

1."Are you still afraid of falling?" 2. "Do you feel safer as a result of the changes in home?"

An individual has undergone accidental poisoning and loses consciousness. Which statement by the caregiver indicates an understanding of emergency care in this situation? 1 "I will position the victim with the head straight." 2 "I know it is never safe to induce vomiting in an unconscious victim." 3 "I will administer ipecac syrup as a home treatment for poisoning." 4 "I should induce vomiting if the victim has ingested hair care products."

2 "I know it is never safe to induce vomiting in an unconscious victim."

In a health care setting, the restraint order for a patient is renewed every hour. What is the likely age of the patient? 1 6 years 2 14 years 3 23 years 4 65 years

2 14 years In a hospital setting, each original restraint order and renewal is limited to 8hours for adults, 2hours for children ages 9 to 17, and one hour for children under the age of 9. Therefore, a restraint order for a 6-year-old child will require renewal every hour. A restraint order for a 14-year-old patient will require renewal every 2 hours. Restraint orders for the 23-year-old and 65-year-old patients will require renewal every 8 hours.

Which nursing activity is performed during the assessment of a patient? 1 Selecting nursing interventions to promote safety 2 Identifying patient perceptions safety needs and risks 3 Consulting with occupational and physical therapists for assistive devices 4 Selecting interventions that will improve the safety of the patient's home environment

2 Identifying patient perceptions safety needs and risks

For a patient who has wrist and ankle restraints, which position will place the patient at risk of aspiration? 1 Sitting 2 Supine 3 Lateral 4 Sleeping

2 Supine

Which question would be appropriate for the nurse to ask when assessing the home maintenance and safety for a patient? 1 "Have you ever suffered an injury from a fall?" 2 "Do you have someone to call in case of an emergency?" 3 "Has your doctor or pharmacist reviewed your medications with you?" 4 "Do you drive an automobile? When do you normally drive? How far?"

2 "Do you have someone to call in case of an emergency?"

The nurse is encouraging a patient with hemiparesis to use coping skills that the patient has used previously. What is a possible reason behind this nursing intervention? 1 To prevent risk of falling 2 To prevent impaired physical mobility 3 To prevent anxiety related to fear of falling 4 To prevent unilateral neglect related to brain injury

3 To prevent anxiety related to fear of falling

The registered nurse is teaching a nursing student about caring for a patient with postural hypotension. Which statement made by the nursing student indicates effective learning? 1 "I should clear the surrounding area." 2 "I will arrange a bedside commode for the patient." 3 "I will help position the patient comfortably in bed." 4 "I will choose a low bed for the patient to practice dangling."

"I will choose a low bed for the patient to practice dangling."

The registered nurse is teaching a group of student nurses about precautions to be taken when using oxygen tanks in a hospital. Which statement made by a student nurse indicates a need for further teaching? 1 "Check the oxygen tank's tubing for kinks." 2 "Post 'No Smoking' signs in patient rooms containing oxygen tanks." 3 "Place the oxygen tanks in an upright position on the floor when not in use." 4 "Take the primary healthcare provider's advice while changing the liter flow of oxygen."

"Place the oxygen tanks in an upright position on the floor when not in use."

Which nursing advice should be given to parents to promote safety for their infant?

"You should take your infant for immunizations."

Which restraint should the nurse use to prevent nerve injury?

Elbow

Which nursing process step is demonstrated when the nurse performs a visual examination on a patient who becomes too agitated when approached?

Evaluation

In a pediatric ward, one of the newborns died of sudden infant death syndrome (SIDS). Which nursing measure lowers the risk of death due to SIDS?

Having the baby sleep on his or her back

The registered staff nurse provides various instructions to the caregiver of an infant before discharge from the hospital. Which instruction promotes safety for the infant?

Install deadbolts on exterior doors above the child's reach.

A patient has been having seizures for more than 30 minutes. The nurse looks after the patient and implements the best efforts to keep the patient safe. Which nursing intervention may lead to complications in the patient?

Restraining the patient to prevent injuries

A patient reports difficulty seeing objects at a distance after a cerebrovascular accident. What would the nurse anticipate?

Risk of falls

The nurse is teaching a group of health care team members in a hospital setting about the interventions and guidelines related to fire. Which order of steps listed by a team member indicates effective learning?

1. Rescue and remove all patients in immediate danger. 2. Activate the alarm. 3. Confine the fire by closing doors and windows. 4. Extinguish the fire with an appropriate extinguisher.

A patient is diagnosed with impaired physical mobility related to left-sided weakness. The registered nurse is teaching the patient's family member about the interventions that would be effective for the patient. Which statement made by the family member indicates effective learning? 1 "I will encourage the patient to use a walker." 2 "I will encourage the patient to use effective coping skills." 3 "I will remind the patient to eat food on the left side of the plate." 4 "I will encourage the patient to touch the left side of the body with the right hand."

1 "I will encourage the patient to use a walker."

Which task related to use of patient restraints can be delegated to nursing assistive personnel (NAP)? 1 Checking on a restraint 2 Assessing a patient's behavior 3 Determining a patient's need for restraints 4 Orientating the patient to the environment

1 Checking on a restraint

The nurse is training a new mother on the use of the Heimlich maneuver. This intervention lowers the risk of which emergency situation? 1 Choking 2 Poisoning 3 Suffocation 4 Head injury

1 Choking

Which care intervention would reduce the risk of sudden infant death syndrome (SIDS)? 1 Immunizing the infant 2 Using snug-fitting sheets 3 Using large soft toys without small hard pieces 4 Avoiding leaving the baby unattended on the changing table

1 Immunizing the infant

While caring for a patient with epilepsy, the nurse recognizes the possibility of tonic-clonic seizure. Which is the priority intervention by the nurse? 1 Positioning the patient safely 2 Helping the patient to stand 3 Conducting a head to toe evaluation 4 Notifying the primary health care provider

1 Positioning the patient safely

A patient who was admitted to the hospital receives a red-color wristband for identification purposes. What is the significance of the wristband? 1 The patient has allergies. 2 The patient is at risk for falling. 3 The patient should be treated immediately. 4 The patient is not indicated for resuscitation

1 The patient has allergies.

Which nursing interventions are appropriate when a patient starts to fall while ambulating? Select all that apply. 1 Calling for assistance 2 Standing with feet apart to provide a broad base of support 3 Bending knees and lowering the body as the patient slides to the floor 4 Following the sentinel event reporting policy of the health care agency 5 Evaluating the patient to determine whether the fall could have been prevented

1 Calling for assistance 2 Standing with feet apart to provide a broad base of support 3 Bending knees and lowering the body as the patient slides to the floor

A patient in a medical-surgical unit develops an acute episode of seizures. Which nursing interventions are performed to ensure a clear airway and free drainage of saliva? Select all that apply. 1 Turn the patient to one side. 2 Tilt the patient's head slightly forward. 3 Place the patient in prone position. 4 Place the patient in supine position. 5 Position the patient's head straight and tilted backwards.

1 Turn the patient to one side. 2 Tilt the patient's head slightly forward.

Which nursing activities are performed during safety planning for a patient? Select all that apply.

1. Consult with occupational and physical therapists for assistive devices. 2. Select interventions that will improve the safety of the patient's home environment.

Which nursing interventions should be followed to safely work with oxygen therapy?

1. Do not use oxygen around electrical equipment. 2. Place the tanks upright on the floor when not in use. 3. Check tubing for kinks that would affect the oxygen flow. 4. Do not change the liter flow without the health care provider's order.

An older adult with diminished eyesight accidentally ingests a toxic substance. Which interventions would the nurse follow when caring for this patient? Select all that apply.

1. Identifying the type and amount of substance ingested 2. Assessing for signs and symptoms of ingestion of harmful substances

What is the correct order of steps for using belt restraints?

1. Placing the patient in a sitting position in the bed 2. Applying the belt over the patient's clothes, gown, or pajamas. 3. Making sure to place the restraint at the waist, and not in the chest or abdomen. 4. Removing wrinkles or creases in the clothing. 5. The patient should be helped to lie down in bed. 6. Helping the patient roll to the side.

The nurse is performing fall prevention measures for a patient. During which step of the nursing process does the nurse perform "Timed Get up and Go" (TUG) if a patient is able to ambulate? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

3 Assessment

Which intervention would be most appropriate to prevent a patient fall by reducing the risk of entanglement? 1 Cleaning all spills promptly and posting a sign indicating a wet floor 2 Removing excess equipment, supplies, and furniture from rooms and halls 3 Coiling and securing excess electrical, telephone, and any other cords or tubing 4 Keeping the floors clutter and obstacle free, particularly the path to the bathroom

3 Coiling and securing excess electrical, telephone, and any other cords or tubing

Which intervention would the nurse employ to reduce the risk of falling in the health care setting due to tripping? 1 Cleaning all spills promptly 2 Ensuring adequate glare-free lighting 3 Keeping the floor free of clutter and obstacles 4 Having assistive devices on the exit side of the bed

3 Keeping the floor free of clutter and obstacles

Which suggestion would be appropriate to prevent unilateral neglect in a patient with hemiparesis? 1 "You should perform range-of-motion exercises." 2 "You should use a walker and cane around the home." 3 "You should consult with an ophthalmologist for visual assessment." 4 "You should touch one side of the body frequently with the other hand."

4 "You should touch one side of the body frequently with the other hand."

A child in the hospital starts to have a grand mal seizure while playing in the playroom. Which is the most important nursing intervention during this situation? 1 Begin cardiopulmonary respiration. 2 Restrain the child to prevent injury. 3 Place a tongue blade over the tongue to prevent aspiration. 4 Clear the area around the child to protect the child from injury.

4 Clear the area around the child to protect the child from injury.

Which skill is implemented by the nurse when planning to prevent falls in patients? 1 Reviewing the patient's medication 2 Making the patient's environment safe 3 Determining if the patient has a history of recent falls 4 Gathering the equipment and performing hand hygiene

4 Gathering the equipment and performing hand hygiene

Which nursing activity is involved in evaluation to determine patient safety? 1 Identifying the patient's preparations of safety needs and risks 2 Identifying the actual and potential threats to the patient's safety 3 Determining the impact of the underlying illness on the patient's safety 4 Reassessing the patient for the presence of physical, social, and environmental risks

4 Reassessing the patient for the presence of physical, social, and environmental risks

While caring for an infant, the nurse places the infant on his/her back. What is the reason for this intervention? 1 Reduce the risk of suffocation 2 Reduce the risk of head injury 3 Reduce the risk of choking and aspiration. 4 Reduce the risk of sudden infant death syndrome (SIDS)

4 Reduce the risk of sudden infant death syndrome (SIDS)

In a health care setting, the restraint order for a patient is renewed every hour. What is the likely age of the patient?

6 years

Which restraint is banned due to the risk of fatal injuries?

Jacket restraint

The nurse is explaining and demonstrating the correct use of fire extinguishers at home to a group of adolescents. Which order of steps listed by an adolescent indicates effective learning?

PASS