NUR FUND PREP U {Chapter 26: Safety, Security, and Emergency Preparedness}

A nurse is caring for an 18 month-old boy status post a tracheostomy. He is recovering well and wanting to be more active. The nurse selects a toy from the playroom for him to play with. Which toy is most developmentally appropriate? Marbles A beaded bracelet A rocking horse Dominos

A rocking horse Rocking horses are a great toy for development of leg muscles.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which of the following measures would be a high priority recommendation for this client? Using restraints on the client to prevent a fall Providing a bed that is elevated from the floor Placing the client in a bed with a bed alarm Raising all the side rails of the bed

Placing the client in a bed with a bed alarm The nurse should attempt to prevent the client confused client from getting out of bed by themselves to prevent a fall using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all 4 siderails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort when the client is in danger of harming themselves or others.

RACE acronym

Rescue anyone in immediate danger. Activate the fire code system and notify the appropriate person. Confine the fire by closing doors and windows. Evacuate patients and other people to a safe area.

The nurse is caring for an 80-year-old patient who was admitted to the hospital in a confused and dehydrated state. After the patient got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this patient? Take the restraints off, stay with her, and talk gently to her. Talk with the patient's family about taking her home because she is out of control. Leave the restraints on and talk with her, explaining that she must calm down. Sedate her with sleeping pills and leave the restraints on.

Take the restraints off, stay with her, and talk gently to her. Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death. The best action in this situation is for the nurse to remove the restraint, stay with the patient and gently talk to her

A client went missing from a long-term care facility and an emergency code was called. After a search of one hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should: 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. Document strategies in the client's health record for preventing future incidents. Complete an incident report in order to determine who was primarily responsible for the event.

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

The nurse is caring for a client with Alzheimer's disease. A family member states, "I am afraid I will go to bed one night, and the next morning my loved one will be missing from wandering off." What is the appropriate nursing response? "Adjust sleeping schedules so that you can monitor your loved one as they sleep." "Consider the Alzheimer's Association 'Safe Return' program." "I know, my parent has Alzheimer's disease and I worry about that too." "Clients with Alzheimer's disease often wander."

"Consider the Alzheimer's Association 'Safe Return' program." The appropriate nursing response is to refer the client's family member to a program such as the Alzheimer's Association's "Safe Return" program. This validates the family member's concern, and provides a resource

A large health care organization has committed to promoting a just culture when adverse events and near misses take place. Which question will guide the organization's response when a nurse commits an error? "Have the client and the family been informed about this?" "What is the organization's legal liability in this matter?" "How have other organizations responded to nurses in events like this?" "How did the nurse's actions contribute to this error?"

"How did the nurse's actions contribute to this error?" Key to the establishment of a just culture is a recognition that not all errors are the same, and that nurses' contributions to errors vary greatly. Legal liability, the response of other organizations, and communication with the client are valid considerations, but none directly promote the establishment of a just culture.

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

Ask to examine the client alone in order to speak to her privately. Explanation: In 90% of elder abuse cases that are reported, the person doing the abusing is a family member. The best thing to do would be for the nurse to get the client alone so that she can discuss the relationship that was observed. Documenting the behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury to the client. The nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols.

Which topics should be included in an education plan for preventing falls in the home? Select all that apply. Keep electrical and telephone cords against the wall and out of walkways. Remove clutter from walkways. Consider the use of an electronic personal alarm. Avoid climbing on a chair or table to reach items that are too high. Consider the use of a raised toilet seat. Use a nightlight.

Avoid climbing on a chair or table to reach items that are too high. Use a nightlight. Remove clutter from walkways. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning? Monitor the activities of the toddler. Avoid unattended baths for the toddler. Allow the child to swim with friends. Instruct the toddler not to go near the pool.

Avoid unattended baths for the toddler The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious.

An administrative assistant of a large factory visits the medical unit and tells the nurse she is having pain in the right wrist, numbness in the index finger, and decreased mobility of the right hand. The nurse suspects the client has what? A herniated cervical disc An infection in the bone Carpal tunnel syndrome A fracture of the hand

Carpal tunnel syndrome Adults with jobs that require repetitive movement (typists, assembly line workers, supermarket checkers, computer operators) may develop carpal tunnel syndrome, a compression of the median nerve that causes pain and decreases hand mobility. A fracture would most likely be accompanied by symptoms including pain, swelling, and an inability to use the extremity. A herniated cervical disk would likely be accompanied by symptoms involving numbness and discomfort of the neck and arms.

A child is playing soccer and is involved in a head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? (Select all that apply.) Headache Fever Drowsiness Increased thirst Vomiting

Drowsiness Headache Vomiting Explanation: Concussions are a frequently seen sports injury in school age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present. Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms usually seen with a concussion.

A client went missing from a long-term care facility and an emergency code was called. After a search of one hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should: document strategies in the client's health record for preventing future incidents. complete an incident report in order to determine who was primarily responsible for the event. 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.

Fill out an incident report, with the goal of preventing a similar event in the future. Explanation: Incident reports are primarily used to facilitate improvements, not to determine culpability. A client's health record is not the appropriate place for documenting strategies for future care. Holding a meeting does not replace the need to document the event in the form of an incident report.

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

Initiate use of a bed alarm. The nurse should attempt to prevent the client confused client from getting out of bed by themselves to prevent a fall using the least restrictive action first.

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls? Maintain a high bed position so the client will not attempt to get out unassisted. Allow the client to use the bathroom independently. Keep the client sedated with tranquilizers. Involve family members in the client's care.

Involve family members in the client's care. Explanation: Family members are an invaluable resource in assessing a client's risk for a fall because they can provide information regarding periods of weakness, confusion/disorientation, and a history of unreported falls. Allowing the client to ambulate independently may further increase the risk of a fall. Sedating a client is a form of chemical restraint, and may cause the client to have an unsteady gait when ambulating. If the client attempts to get out of bed a high bed position would cause more injury to the client if a fall occurs.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home? Most fatal home fires occur while people are cooking. About 10% of home fire deaths occur in a home without a smoke detector. Most people who die in house fires die of smoke inhalation, rather than burns. Most home fires are caused by children playing with matches.

Most people who die in house fires die of smoke inhalation, rather than burns. Explanation: Most people who die in house fires die of smoke inhalation, rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping.

What best describes the nurse's role in disaster preparedness? a) Administration of all of the medications b) Performance of all of the skills such as IV insertion and wound care c) Multiple roles including triage and the distribution of resources d) Counseling the victims and families

Multiple roles including triage and the distribution of resources Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources.

Which level of health care provider may make the decision to apply physical restraints to a client? RN nurse manager LPN team leader Nurse practitioner Senior personal care assistant

Nurse practitioner Explanation: Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such as The Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician assistant.

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety? "Any helmet is appropriate for bicycle riding because all children should wear helmets when riding." "The chinstrap on the helmet should be adjusted to fit loosely so that it does not choke the child." "Young children secured in a bicycle passenger seat do not have to wear a helmet." "Parents are effective role models for children when they also wear helmets while riding."

Parents are effective role models for children when they also wear helmets while riding." Explanation: Parents are effective role models for children when they also wear helmets while riding. Helmets that have been damaged in a crash should not be worn. The chinstrap should fit snuggly, not loosely, and young children that are secured in a bicycle passenger seat must also wear a helmet.

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

Providing prompt recognition of the potential or actual threat to safety Explanation: The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment.

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 to remain plugged in. Refrain from using extension cords. Remove the plug from the wall by pulling the electric cord.

Refrain from using extension cords. Explanation: Extension cords should not be used, so that overload is not placed on electric wires and circuits. For safest practices that decrease risk for electric shock, outlets and switches should be covered, machines that are used infrequently should be unplugged, and plugs should be removed from the wall by grasping the actual plug (not the cord).

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. Which of the following should be the nurse's first action? Close the client's door. Activate the fire alarm. Obtain the fire extinguisher. Remove the client from the room.

Remove the client from the room. Explanation: In case of a fire, the nurse should rescue anyone in immediate danger; activate the fire code system and notify the appropriate person; and confine the fire by closing doors and windows in this order. Therefore, in this instance, the nurse's first action should be to remove the client from the room.

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan? Give warm bottles of formula to the baby. Lock all cabinets that contain cleaning supplies. Restrain the baby in a car seat. Keep all pots and pans in lower cabinets.

Restrain the baby in a car seat. Explanation: The client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets and giving warm bottles of formula to the baby are secondary teachings.

The nurse is assessing the client's sensory input. Which assessments should be included? Select all that apply. Sensitivity of sharp to dull stimulation Pupil sensitivity to light changes Sensitivity to touch Ability to maintain balance Sbility to recall information

Sensitivity to touch Sensitivity of sharp to dull stimulation Ability to maintain balance Explanation: Examination of sensory function allows the nurse to verify the accuracy and quality of sensory input. Testing should include ability to balance, sensitivity to sharp versus dull stimulation, and sensitivity to light touch of the extremities.

The nurse is educating parents of toddlers on how to prevent injuries and promote safety for their children. What are age-appropriate safety interventions for this age group? Select all that apply. Do not leave the child alone in the bathtub or near water. Childproof the house to ensure that poisonous products and small objects are out of reach. Instruct the child to wear proper safety equipment when riding bicycles or scooters. Provide drug, alcohol, and sexuality education. Practice emergency evacuation measures with the child. Supervise the child closely to prevent injury.

Supervise the child closely to prevent injury. Childproof the house to ensure that poisonous products and small objects are out of reach. Do not leave the child alone in the bathtub or near water. Explanation: Measures to prevent injuries and promote safety of toddlers include having the poison control center phone number in readily accessible location. Using an appropriate car seat for the toddler; supervising the child closely to prevent injury; childproofing the house to ensure that poisonous products, drugs, and small objects are out of toddler's reach; Never leaving the child alone and unsupervised outside; and keeping all hot items on the stove out of the child's reach. Proper safety equipment for bicycles and scooters, and practicing emergency evacuation measures, are appropriate education measures for the preschooler. Providing drug, alcohol, and sexuality information is appropriate for the school-age child.

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse? The 2-year-old and 6-year-old each holding the mother's hand. The 2-year-old helping mom to open the front door of the school. The 2-year-old leaning against the screen of a window in a classroom. The 6-year-old riding a bike on the playground with his friend.

The 2-year-old leaning against the screen of a window in a classroom.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure ulcer on his 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? CMS may choose to divert clients to other health care facilities in the future. The hospital will be fined by CMS because the client developed a pressure ulcer. CMS will bear the hospital's costs if the client chooses to sue the hospital. The hospital must bear any costs incurred for treating the client's ulcer.

The hospital must bear any costs incurred for treating the client's ulcer. Explanation: If 'never events' occur while a client is hospitalized, the cost of the care associated with that event will not be paid by CMS, but will be borne by the hospital. Fines are not levied against the hospital, however, and CMS does not actively divert clients to other facilities. CMS does not pay damages on behalf of hospitals.

The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include? The importance of practicing moderation when consuming alcohol The importance of consistent seat belt use Identification of hazards associate with falls Avoiding workplace injury

The importance of consistent seat belt use

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.

The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing.

A nurse was injured when a client with Alzheimer's disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate? The incident report is reviewed by state agencies and the Occupational Safety and Health Administration rather than by hospital administration. The client and the client's family will be required to sign the report, acknowledging that they read it before it was filed. The report provides a detailed and objective account of the circumstances before, during, and after the event. The report becomes a confidential part of the client's health record once it is reviewed by hospital administration.

The report provides a detailed and objective account of the circumstances before, during, and after the event. Incident reports are used for internal review and improvements to systems. They include detailed descriptions of the event in question. They do not become part of the client's health record. They are often provided to outside agencies, but they do not bypass the institution where the event occurred. Clients and their families do not sign incident reports.

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

a dose of an antipsychotic Chemical restraints are medications, such as an antipsychotic, that are used to manage a client's behavior or freedom of movement. Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint.

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety? Administering medications to the client Transferring the client from one location in the hospital to another Admitting the client to the health care facility Electronically reporting the results of diagnostic testing to the client's primary care provider

administering medications to the client Explanation: A large proportion of adverse events in hospital settings involves medication administration. It is generally accepted that medication administration is more risky than communication of testing results, client transfers, or client admissions.

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age? "Never keep firearms in the home with young children." "Always provide close supervision for young children when they are in or around pools and bathtubs." "Never smoke in the bed in the house when young children are present." "Store medications in a locked area to prevent children from getting into them."

b) "Always provide close supervision for young children when they are in or around pools and bathtubs."

The surgical nurse is preparing a client for surgery on the left leg. The client is awake, alert, and oriented. Who does the nurse identify that should mark the leg that will undergo the surgical procedure? (Select all that apply.) nurse client surgeon unlicensed assistive personnel family member

nurse surgeon client Explanation: To prevent wrong site, wrong procedure, and wrong person surgery, the nurse and surgeon will mark the left leg as the one intended for surgery, and have the client mark the body part intended for surgery. A UAP should never mark the surgical site, nor should the family member mark the site for a client who is lucid.