Nursing Fundamental - Chapter 28 Safety

A client arrives at the emergency department after an industrial explosion involving an unknown chemical contaminant. What is the nurse's priority action? Assess client's respiratory depth and effort Activate external disaster protocol Identify chemical agent before treating Flush skin while rinsing with sterile saline

Activate external disaster protocol

A school nurse is teaching a group of adolescents about safe driving. What behavior(s) should the nurse encourage to promote safe driving? Select all that apply. Always wear a seat belt. Drive at night when fewer people are on the road. Limit the number of other adolescents in the car. Never text while driving. Obey the speed limit.

Always wear a seat belt. Limit the number of other adolescents in the car. Never text while driving. Obey the speed limit.

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.

Assess for the need to urinate.

The nurse is caring for an older adult client who has a cognitive impairment and frequently wanders. The nurse will implement which action(s) into the client's plan of care? Select all that apply. Apply physical restraints at regular periods throughout the day. Have facility security personnel assist when the client is agitated. Check that all exit doorways have a STOP sign posted. Encourage the client to walk outdoors when weather permits. Place a bell over the client's room and other facility doors.

Check that all exit doorways have a STOP sign posted. Place a bell over the client's room and other facility doors.

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan? Childproofing the house Smoking cessation Safety equipment for playing sports Back to sleep guidelines

Childproofing the house

During discharge planning, the nurse is assessing home safety for a client who has repeatedly fallen. Which risk factor(s) for falls should the nurse identify? Select all that apply. Client climbs two flights of stairway to get to their bedroom. Client prefers to use the bathtub when taking a bath. Client has two alcoholic beverages before dinner. Client takes a diuretic early in the morning. Client uses nonskid socks all day.

Client climbs two flights of stairway to get to their bedroom. Client prefers to use the bathtub when taking a bath. Client has two alcoholic beverages before dinner. Client takes a diuretic early in the morning.

The nurse is caring for a client who has been placed in physical restraints. Which nursing action is appropriate? Select all that apply. Obtain a health care provider order 2 hours after restraints are applied. Communicate with the family regarding the need for restraints. Check circulation and skin condition frequently and regularly. Offer opportunities for toileting frequently and regularly. Continue using the restraints until discharge.

Communicate with the family regarding the need for restraints. Check circulation and skin condition frequently and regularly. Offer opportunities for toileting frequently and regularly.

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

nurse practitioner

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

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

The nurse is providing safety education to a group of adolescents. What teaching point should the nurse prioritize? fire prevention and fire safety obligation to report any unsafe actions to authorities value of not giving into social pressure to perform unsafe acts infection control and strategies for breaking the chain of infection

value of not giving into social pressure to perform unsafe acts

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? "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." "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."

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important? "Make sure that you have smoke detectors in your house and that they're in working order." "If your clothes should catch on fire, go to an open area as quickly as possible." "Make sure that your family's microwave oven was made after 1999; otherwise, it may be a fire risk." "A wood-burning fireplace is a major fire risk, and it shouldn't be used unless necessary."

"Make sure that you have smoke detectors in your house and that they're in working order."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention? "I will rescue clients from harm before doing anything else." "After clients are evacuated from the room with the fire, the alarm can be sounded." "I will close the door to the room where the fire is after clients have been removed." "Only certain members of the health care team can extinguish a fire."

"Only certain members of the health care team can extinguish a fire."

The nurse is presenting content on fire safety to a family. One of the family members tells the nurse that they have designated a meeting spot in their front yard in case of fire and that they practice using escape routes. Which is the nurse's best response? "That is an important part of an overall fire safety plan." "It is preferable to have a meeting place that's at least 100 yards from your home." "It is preferable to focus on fire extinguisher safety, because most people cannot follow escape routes in a fire." "Make sure your escape route passes through each family member's bedroom."

"That is an important part of an overall fire safety plan."

A nurse failed to document the administration of a client's warfarin and the nurse on the next shift administered the drug again, believing that it had been overlooked. When performing root cause analysis, what question should be asked first? "Has this, or something very similar, ever happened on the unit before?" "Why did the second nurse administer this drug to the client?" "What could the two nurses have done to ensure this did not happen?" "What were the possible adverse outcomes that could have resulted from this error?"

"What could the two nurses have done to ensure this did not happen?"

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

19-year-old male college student majoring in physics

The facility is conducting an educational seminar for newly employed nurses. The program addresses the reporting of sentinel events. Which occurrences qualify for this criteria? Select all that apply. A client reports plans to file a complaint concerning the amount of time it took for a nurse to respond to a call light. A client's infant is misidentified and receives breast milk from another mother. A client faints during ambulation with the nurse, resulting in a concussion. The nurse administers a lethal dosage of medication in error.

A client's infant is misidentified and receives breast milk from another mother. A client experiences a reaction to a unit of blood, resulting in itching and hives. A client faints during ambulation with the nurse, resulting in a concussion. The nurse administers a lethal dosage of medication in error.

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

A nurse who has worked 32 hours of overtime this week

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? Request a sedative from health care provider Conceal IV tubing with gauze wrap Ask visiting family member to stay Assure bed alarms are activated

Conceal IV tubing with gauze wrap

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse? Perform a vision test with Snellen chart Arrange an audiology consult to evaluate hearing Assess the client for signs and symptoms of osteoporosis Arrange for a skilled home care assessment

Arrange for a skilled home care assessment

Which topics should be included in an education plan for preventing falls in the home? Select all that apply. 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. Consider the use of an electronic personal alarm.

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 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

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

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

Extremity restraint

When educating families on fire safety in the home, which information is important for the nurse to emphasize? Have a meeting place outside the home in case of fire. Account for all members and then exit together. Use extension cords to prevent shock. Keep a fire extinguisher in a closet.

Have a meeting place outside the home in case of fire.

What teaching will the community health nurse include for parents of toddlers? Place the child securely on a changing table. Household cleaners must be kept out of reach. Purchase protective sporting equipment. Peer pressure can contribute to risk-taking.

Household cleaners must be kept out of reach.

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 health care provider 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.

Initiate use of a bed alarm.

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? Investigate the possibility of discontinuing his or her catheter. Limit the resident's fluid intake in order to reduce his or her urge to void. Collaborate with the resident's health care provider to have his or her diuretics discontinued. Increase the resident's physical activity to reduce evening restlessness.

Investigate the possibility of discontinuing his or her catheter.

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.

Obtain order from a licensed provider within minutes of restraint application. Check circulation and skin condition every 2 hours.

The nurse is providing care for an older adult client with a hip fracture utilizing a walker. Which action by the nurse would be the priority? Assess the mobility of the client Monitor neurological status Place a falls risk bracelet on client Provide 1:1 companionship at bedside

Place a falls risk bracelet on client

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 measure would be a priority recommendation for this client? Placing the client in a bed with a bed alarm Providing a bed that is elevated from the floor Raising all the side rails of the bed Using restraints on the client to prevent a fall

Placing the client in a bed with a bed alarm

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. The adult child asks, "What can I do to keep my parent safe?" What are the best instruction(s) by the nurse? Select all that apply. Provide frequent reorientation. Ensure the parent engages in regular exercise. Increase the parent's social interaction. Ensure the parent takes naps frequently. Ensure that the parent's routine changes frequently.

Provide frequent reorientation. Ensure the parent engages in regular exercise. Increase the parent's social interaction.

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.

Pull the fire alarm lever.

A nurse is completing an intake assessment. The nurse notes that an older adult client appears to have bruises in varying stages of healing. Which action should the nurse take first? Notify the primary care provider about the bruises. Contact the facility's social work department. Question the client about the source of the bruises. Request permission from the client to photograph the bruises.

Question the client about the source of the bruises.

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

Reduce distressing environmental stimuli to maximize client safety

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply. Remove extension cords from open spaces. Check the batteries in all smoke detectors. Store prescription medications on the counter. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas.

Remove extension cords from open spaces. Check the batteries in all smoke detectors. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas.

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected the client with an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident? Report this sentinel event to The Joint Commission and to relevant state agencies. Inform the public that the incident occurred, while protecting the confidentiality of the clients. File an incident report with the American Nurses Association describing plans for preventing similar events in the future. Offer compensation to the affected client in a timely manner, while maintaining the client's confidentiality.

Report this sentinel event to The Joint Commission and to relevant state agencies.

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? Rescue anyone who is in immediate danger. Evacuate clients and staff. Activate the fire alarm on the unit. Attempt to extinguish the fire.

Rescue anyone who is in immediate danger.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client 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 client? Sedate her with sleeping pills and leave the restraints on. Take the restraints off, stay with her, and talk gently to her. Leave the restraints on and talk with her, explaining that she must calm down. Talk with the client's family about taking her home because she is out of control.

Take the restraints off, stay with her, and talk gently to her.

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply. Takes furosemide daily Admits to drinking wine through the evening Shares a one floor living space with a spouse Has history of diabetic neuropathy Participates in a walking club

Takes furosemide daily Admits to drinking wine through the evening Has history of diabetic neuropathy

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply. The client is wearing the oxygen around the neck. There is spilled water on the floor. The IV is not infusing at the correct rate. The skin is a bluish-color. The client's television is turned off.

The client is wearing the oxygen around the neck. There is spilled water on the floor. The IV is not infusing at the correct rate. The skin is a bluish-color.

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

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

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 health care provider offices. The nurse uses computer-generated care plans for client care.

The nurse researches best current practices for prevention of the spread of infection in health care provider offices.

The nurse uses the QSEN competency of Informatics when planning care for clients. What is an example of the use of this skill? The nurse works collaboratively with a dietitian to devise a client meal plan. The nurse orients a visually impaired client to the hospital room. The nurse checks with the client for priorities when planning client care. The nurse researches new technological advances in the treatment of cancer.

The nurse researches new technological advances in the treatment of cancer.

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 should record the incident in the client's medical record and fill out a safety event report separately.

A parent who is caring for their13-year-old child asks the nurse why they could be performing poorly in school lately, and why they are distancing themselves from friends and family. Which of these possibilities would the nurse consider as the priority risk? They may be the victim of cyber-bullying. They have lost interest in academics because they are dating now. They are experiencing puberty. They are developing nutritional deficiencies from poor dietary habits.

They may be the victim of cyber-bullying.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? Respond to the past history of the client (including previous falls) to determine the need for restraints. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. Individualize the use of restraints and choose the most easily used device. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

A pediatric nurse is discussing injury prevention with a group of new parents. What are the leading causes of mortality and morbidity in children? Select all that apply. Unintentional gunshot wounds Drowning Accidental poisoning Suffocation Complications of medical care

Unintentional gunshot wounds Drowning Accidental poisoning Suffocation

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.

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.

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.

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.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate? application of devices that reduce the client's ability to move arms administration of an antipsychotic agent to alter the client's behavior asking the unlicensed assistive personnel (UAP) to sit with the client articulating the reason for use of a physical restrictive device to the client's spouse

administration of an antipsychotic agent to alter the client's behavior

The nurse has delegated several parts of basic care for a client who is a fall risk to an unlicensed assistive personnel (UAP) member. Which UAP action requires nursing intervention? placing the bed into the lowest setting assisting the client to put on slippers prior to ambulation assuring that there is a clear path between the bathroom and bed reminding the client to sit on the bed for a few moments before standing

assisting the client to put on slippers prior to ambulation

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."

breathing

The residential home nurse is caring for a client who lives in an assisted living unit. In designing a plan of care to prevent fires, the nurse identifies which as the highest risk to the client? clothes dryer gas stove electrical sockets cigarette smoking

gas stove

A public health nurse is providing community education to older adults regarding their risk of poisoning. Which information does the nurse include in the teaching? keeping medications in clearly labeled containers using alternatives to chemical-based cleaning supplies reviewing hidden sources of lead in the household environment avoiding the use of alternative and complementary therapies

keeping medications in clearly labeled containers