Safety

An appropriately worded goal associated with the nursing diagnosis Risk for Injury is, "The patient will be: 1. Taught how to call for help to ambulate." 2. Kept on bed rest when dizzy." 3. Restrained when agitated." 4. Free from trauma."

4. Free from trauma." Rationale: The first 3 are planned interventions, while the last one is a goal

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client? Assessment of head circumference Assessment of vital signs and respiratory status Evaluation of all of his cranial nerves Initiation of a peripheral intravenous (IV) line for fluid administration

Assessment of vital signs and respiratory status. Remember PRIORITY or IMMEDIATE includes ABCs. Assessment of vs and respiratory status is a priority for this client. Eval of his cranial nerves should NOT take priority over cardiopulmonary assessment. Assessment comes before intervention in the nursing process.

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 helping mom to open the front door of the school. 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. The 2-year-old and 6-year-old each holding the mother's hand.

The 2-year-old leaning against the screen of a window in a classroom. Rationale: Windows are a concern for toddlers.

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death? Fifth Tenth First Eighth

5th Rationale: After heart disease, cancer, stroke, and chronic obstructive lung disease.

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, but has no history of falls An 80-year-old female with a history of falling last year and breaking a hip

A 70-year-old female with postural hypotension who wears eyeglasses, but has no history of falls Rationale: This patient has 3 RISK FACTORS These are the risk factors: 1. Being over 65 2. Hx of falls 3. Impaired vision or sense of balance 4. Postural hypotension 5. Altered posture or gait 6. Meds = diuretics (pee more often), tranquilizers, sedatives, hypnotics, or analgesics (makes you sleepy) 7. Slowed reaction time 8. Confusion/disorientation 9. Impaired mobility 10. Weakness/physical frailty 11. Unfamiliar environment

14. The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? The nurse positions a patient in a supine position prior to applying wrist restraints. The nurse ensures that two fingers can be inserted between the restraint and patient's ankle. The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist. The nurse ties an elbow restraint to the raised side rail of a patient's bed.

The nurse ensures that two fingers can be inserted between the restraint and patient's ankle. Rationale: The patient should not be put in a supine position with restraints due to risk of aspiration. IV on right wrist, alternative forms of restraints should be tried like cloth mitt or elbow restraint.

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? "Store medications in a locked area to prevent children from getting into them." "Never smoke in the bed in the house when young children are present." "Always provide close supervision for young children when they are in or around pools and bathtubs." "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." Rationale: Leading cause of death of children 1-4 is drowning

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? "Clients with Alzheimer's disease often wander." "Consider the Alzheimer's Association 'Safe Return' program." "Adjust sleeping schedules so that you can monitor your loved one as they sleep." "I know, my parent has Alzheimer's disease and I worry about that too."

"Consider the Alzheimer's Association 'Safe Return' program." Rationale: Giving family member resource.

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective? "I will rescue clients from harm before doing anything else." "I will sound the alarm before I start moving a patient from a room." "I will leave all doors open after rescuing patients." "I know that nurses are the only ones who can extinguish a fire."

"I will rescue clients from harm before doing anything else." Rationale: Remember, RACE = Rescue, alarm, confine, and extinguish.

Owen is a 15-year-old client who is waking up postoperatively. He became combative and tried to strangle one of the nurses. A support team was called and 4-point restraints were applied in this emergent situation. How soon does a licensed provider need to assess the client and place the restraint order? 15 minutes 4 hours 1 hour 30 minutes

1 hour Rationale: Restraints can be placed immediately for emergency situations without an order, but patients need to be assessed within 1 hour of restraint placement (apparently)

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 Dominos A rocking horse A beaded bracelet

A rocking horse Rationale: Obvi he can choke on the other ones. Rocking horses are a great toy for development of leg muscles.

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention? Flag the room door. Apply an allergy-alert identification bracelet on the client. Notify the interdisciplinary healthcare team to use nonlatex equipment. Teach client to wear Medic-Alert bracelet.

Apply an allergy-alert identification bracelet on the client. Rationale: Apply this bracelet so ANY member of the interdisciplinary team can quickly identify the latex allergy.

What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household? Avoid stuffed animals and blankets in the crib. Educate about, and be aware of, signs of risky behaviors. Include safeguards to prevent falls in the home. Teach seat belt safety.

Avoid stuffed animals and blankets in the crib. Rationale: Newborns esp before the age of 4 months are prone to suffocation. Toddlers and older children = falls. Teens = Risky behaviors.

The nurse is teaching the caregiver of a school-age 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 task risks.

Buy protective sporting equipment. Rationale: Children at this age group are learning how to play sports and being more active. This is most appropriate. 1. They don't need to be changed (infants) 2. They probably won't chug any household cleaners because they have enough common sense not to. Common for toddlers 4. Peer pressure doesn't really start until like teens

5. A nurse working in a busy emergency department is caring for a teenage patient who presents with a burning pain in his mouth, edema of the lips, vomiting, and hemoptysis. The teen admits that he was playing a dare game with friends and was forced to swallow a drain opener preparation. What would be the nurse's priority intervention? Induce vomiting and call the primary care provider. Perform stomach lavage and call the poison control center. Give activated charcoal orally and call the physician. Dilute the poison with milk and call the primary care provider.

Dilute the poison with milk and call the primary care provider. Rationale: Drain opener = dilute with milk or water. For vitamin preps, stomach lavage (stomach pumping = cleaning out the contents of the stomach) = to remove undigested pills Acetaminophen poisoning, activated charcoal may be used.

13. An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints? Sitting him in a geriatric chair near the nurses' station Using the sheets to secure him snugly in his bed Keeping the bed in the high position Identifying his door with his picture and a balloon

Identifying his door with his picture and a balloon Rationale: This method allows patient to wander, but he is able to find his room easier. The next alternate is not letting the patient wander. Geriatric chair and sheets are forms of physical restraint. Leaving bed in high position leaves the patient with the risk of falling.

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply. Communication ability Community population Developmental level Mobility Type of health care facility

Mobility, Communication ability, and Developmental level. Rationale: Factors that impact safety include: 1. developmental level 2. lifestyle 3. mobility 4. sensory perception 5. knowledge level 6. communication ability 7. physical/psychosocial state.

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.

Reduce the temperature on the water heater. Rationale: -Safe environments for older adults include comfortable temp range, adequate clothing, bath water on right temperature, ventilation, lighting. Neuropathy is = damage to the peripheral nerves = having trouble sensing things

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? Close the client's door. Activate the fire alarm. Remove the client from the room. Obtain the fire extinguisher.

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

A client who was receiving care on a psychiatric unit committed suicide at a time when nurses are known to be handing off to nurses on the next shift. What is a responsibility of the organization when responding to this sentinel event? Inform local health care institutions about the event in order to promote safety. Change the institution's policies regarding supervision of clients. Appropriately discipline the nurses who were participating in the shift change. Report the event to the Joint Commission.

Report the event to the Joint Commission. Rationale: Sentinel events are serious safety events and need to be sent to the appropraite regulatory agency like the Joint Commission and to the state health agencies.

4. While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? Impaired Gas Exchange related to cigarette smoking Anxiety related to inability to stop smoking Risk for Suffocation related to unfamiliarity with fire prevention guidelines Deficient Knowledge related to lack of follow-through of recommendation to stop smoking

Risk for Suffocation related to unfamiliarity with fire prevention guidelines Rationale: Smoking in bed is extremely dangerous, she could suffocate from fire while she sleeps.

A nurse is assessing a client who was exposed to botulism from contaminated food supplies. Which symptom would the nurse expect to find in this client? Skin lesion with local edema that progresses, enlarges, ulcerates, and becomes necrotic Flu-like symptoms Skeletal muscle paralysis that progresses symmetrically and in a descending manner Petechial hemorrhages

Skeletal muscle paralysis that progresses symmetrically and in a descending manner Rationale: Exposure to botulism results in skeletal muscle paralysis that progresses symmetrically and in a descending manner. Muscle weakness and respiratory failure are s/s. Smallpox = flu-like s/s Skin lesions with local edema that worsens = anthrax Petechial hemorrhages = Viral hemorrhagic fevers

What is the most appropriate outcome for the client who has a nursing diagnosis of "Risk for Injury related to the use of assistive mobility devices in an unfamiliar environment?" The client will demonstrate safety measures to prevent falls. The client will establish safety priorities with family members. The client will identify resources for safety information. The client will identify unsafe situations in his or her environment.

The client will demonstrate safety measures to prevent falls. Rationale: -Establishing safety priorities with family members CAN help, but it isn't the most appropriate outcome for the client right now. Identifying resources isn't going to fix the patient's nursing dx. -The nurse should determine that the client is at risk for falls = a good outcome would be to prevent falls.

Which factor is related to the highest proportion of falls in long-term care settings? Toileting Agitation Polypharmacy Impaired sleep patterns

Toileting Rationale: 42% of falls were related to toileting, often involving getting out of bed or walking to the bathroom.

The nurse is teaching a nursing student about proper latex glove use. Which teaching will the nurse include? Use hand cream or lotion after removing gloves to preserve skin integrity. Wash hands thoroughly after removing gloves with a pH balanced soap. Snap the gloves when applying them to ensure proper fit. Use powdered gloves.

Wash hands thoroughly after removing gloves with a pH balanced soap. Rationale: Use pH balanced soap after using latex gloves.

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? "Consider the Alzheimer's Association 'Safe Return' program." "Adjust sleeping schedules so that you can monitor your loved one as they sleep." "Clients with Alzheimer's disease often wander." "I know, my parent has Alzheimer's disease and I worry about that too."

"Consider the Alzheimer's Association 'Safe Return' program." Rationale: 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? "How did the nurse's actions contribute to this error?" "How have other organizations responded to nurses in events like this?" "Have the client and the family been informed about this?" "What is the organization's legal liability in this matter?"

"How did the nurse's actions contribute to this error?" Rationale: Key to just culture is a recognition that not all errors are the same, and that nurses' contribution to errors vary greatly.

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for a 9-month-old infant? "We place our baby in a front-facing car seat in the middle of the back seat of the car." "We place our baby in a front-facing car seat in the front of the car so that he doesn't cry." "We place our baby in a rear-facing car seat in the back seat of the car." "We place our baby in a rear-facing car seat in the front of the car so that we can see him in case he chokes.

"We place our baby in a rear-facing car seat in the back seat of the car." Rationale: Infants until the age of 2 should be in the rear-facing infant seat in the back seat of the care until they reach the max height and weight for a front-facing child car seat.

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 3-year-old child? "We place our child in a front-facing car seat in the back seat of the car." "We place our child in a front-facing car seat in the front of the car." "We place our child in a rear-facing car seat in the back seat of the car." "We place our child in a rear-facing car seat in the front of the car."

"We place our child in a front-facing car seat in the back seat of the car." Rationale: Children over age of 2 should be placed in FRONT-FACING car seat based on weight and height. Less than 2 should be BACK-FACING car seat.

Which clients are most at risk for falling due to altered mobility? Select all that apply. A client with a spinal cord injury A middle-aged woman who had surgery 2 weeks ago and wears high heels All older adults An older adult client with an unsteady gait A client who requires crutches in unfamiliar health care settings

1. A client with a spinal cord injury 2. An older adult client with an unsteady gait 3. A client who requires crutches in unfamiliar health care settings Rationale: Not the middle-aged woman because Prep U says they aren't most at risk for falling (bih what lol). -Limitations in mobility are unsafe and cause client injury. -Remember not to choose answers with "all", "always", "never" in them lol

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply. A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. Fires are responsible for most hospital incidents. Between 15% and 25% of falls result in fractures or soft tissue injury. A medication regimen that includes diuretics or analgesics places an individual at risk for falls. A nurse whose behavior is reasonable and prudent, and similar to what would be expected of another nurse in a similar circumstance, is still likely to be found liable if a client falls, especially if an injury results.

1. A person with a history of falls is likely to fall again. 2. Some people are more at risk for accidents than others. 3. A medication regimen that includes diuretics or analgesics places an individual at risk for falls. Rationale: -Person with hx of fall are at risk for falls in the future. -Some people are more careless and more at risk for falls -FALLS not fires are responsible for most hospital incidents. -~33% of falls result in fx or soft issue injury -A med regimen with diuretics or analgesics (causes unsteady gait due to drowsiness) = risk for falls

A nurse is applying restraints to a confused client who has threatened the safety of a roommate. Which actions would the nurse perform when properly applying restraints to a client? Select all that apply. Check agency policy for the application of restraints and secure a physician's order. Choose the most restrictive type of device that allows the least amount of mobility. Pad bony prominences. For a restraint applied to an extremity, ensure that the restraint is tight enough that a finger cannot be inserted between the restraint and the client's wrist or ankle. Fasten the restraint to the side rail. Remove the restraint at least every 2 hours or according to agency policy and client need.

1. Check agency policy for the application of restraints and secure a physician's order. 2. Pad bony prominences. 3. Remove the restraint at least every 2 hours or according to agency policy and client need. Rationale: -You need MD orders for restraints after having a justifiable reason such as threatening the safety of another pt, pad bony prominence to avoid injury to those areas so circulation is not impaired -Least restrictive type -A finger should be able to find so that the restraint is not too tight -Fastened to non-moving parts of the bed = side rails can injure the attached body parts when someone moves it

The nurse is caring for a client with a latex allergy. Which nursing interventions are appropriate? (Select all that apply.) Communicate to the interdisciplinary healthcare team to use nonlatex equipment. Teach client to wear Medic-Alert bracelet. Remove blueberries from the client's dietary tray. Assign client to a semi-private room so roommate can report any reactions. Flag the chart and room door. Apply an allergy-alert identification bracelet on the client.

1. Communicate to the interdisciplinary healthcare team to use nonlatex equipment. 2. Teach client to wear Medic-Alert bracelet. 3. Flag the chart and room door. 4. Apply an allergy-alert identification bracelet on the client. Rationale: Chart and room should reflect patient's latex allergy. Other healthcare personnel should know about the allergy as well. The nurse will teach the client to wear a Medic-Alert bracelet at all times for safety purposes. Used to identify important medical information

The nurse must apply a hospital gown to a patient receiving an intravenous infusion in the forearm. The nurse should: 1. Insert the 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

1. Insert the IV bag and tubing through the sleeve from inside of the gown first Rationale: Prevents tension on the IV and limits unnecessary exposure to enfection

A client has been diagnosed with a glioblastoma and the care team has determined that this brain tumor is inoperable. Which aspects of the the client's subsequent care demonstrate adherence to the Quality and Safety Education for Nurses (QSEN) competencies? Select all that apply. The care team meets with the client and family promptly to identify their preferences for treatment. The care team balances the best available evidence about glioblastoma treatment with the client's preferences. Nurses proactively identify threats to the client's safety that may occur as treatment is provided. Each member of the care team uses the best available technology to organize and provide care. Treatments are chosen with the goal of minimizing the financial burden on the health care institution.

1. The care team meets with the client and family promptly to identify their preferences for treatment. 2. The care team balances the best available evidence about glioblastoma treatment with the client's preferences. 3. Nurses proactively identify threats to the client's safety that may occur as treatment is provided. 4. Each member of the care team uses the best available technology to organize and provide care. Rationale: 1. is patient centered care, 2. use of knowledge and evidence and team collab, 3. Safety, 4. team collab and use of technology (informatics) -QSEN is NOT concerned with financial probs

During discharge planning, the nurse is assessing home safety for a client who has repeatedly fallen. Which condition increases the client's risk for falls? Select all that apply. climbs two flights of stairway to get to his bedroom prefers to use the bathtub when taking a bath drinks 2 shots of alcoholic beverages before dinner takes a diuretic pill early in the morning uses non-skid socks all day

1. climbs two flights of stairway to get to his bedroom 2.prefers to use the bathtub when taking a bath 3. drinks 2 shots of alcoholic beverages before dinner 4. takes a diuretic pill early in the morning Rationale: Uh the non-skid socks mean they aren't going to slip (LOL crey), these are all safety risks. Alcohol is too because it can impair judgement = lead to falls

The nurse is planning care for a patient who requires bilateral arm restraints. Which information is important to understand when planning care for this patient? 1. Their use adequately prevents injuries 2. They require a physician's order to be applied 3. Reasons for their use must be clearly documented 4. Most patients recognize that they contribute to their safety

3. Reasons for their use must be clearly documented Rationale: Restraints can be applied in emergency situations to protect patients from harming themselves or others. Physican's order must be obtained within 12hr.

The nurse is planning care for a patient with a wrist restraint. The restraint should be removed, the area massaged, and the joints moved through their full range every: 1. Shift 2. Hour 3. Two hours 4. Four hours

3. Two hours

The nurse is caring for a confused patient. To prevent this patient from falling, the nurse should: 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

4. Maintain close supervision Rationale: Confused patients may not be able to understand you when you encourage, reinforce them, or even when you place them closer to the nurses' station. So you can't leave them by themselves.

The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. A patient who is older than 60 years A patient who has already fallen twice A patient who is taking antibiotics A patient who experiences postural hypotension A patient who is experiencing nausea from chemotherapy A 70-year old patient who is transferred to long-term care

A patient who has already fallen twice, A patient who experiences postural hypotension, A 70-year old patient who is transferred to long-term care Rationale: Risk factors for falls include a) patients over 65+, b) documented hx of falls, c) postural hypotension, and d) unfamiliar environment. Meds including: diuretics, tranquilizers, sedatives, hypnotics, or analgesics are also risk factors, but NOT chemo or antibiotics.

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply. Client-centered care Teamwork and collaboration Establishment of clinical career ladders Revamping the licensing requirements for foreign-educated nurses Quality improvement (QI)

Client-centered care, Teamwork and collaboration, and Quality improvement (QI) Rationale: The Quality and Safety Education for Nurses (QSEN) project is designed to provide a framework for knowledge, attitudes, and skills needed for future nurses. 6 competencies = 1. Client-centered care, 2. teamwork/collab, 3. evidence-based practice, 4. quality improvement, 5. safety, 6. informatics.

Which statement should the nurse include in the education plan regarding safety issues for a group of adult clients? In most age groups, motor vehicle accidents are major causes of death. Suicide is the leading cause of death in adults and adolescents. Occupational safety practices can eliminate all workplace hazards. Environmental lead exposure is a primary cause of death in adult clients.

In most age groups, motor vehicle accidents are major causes of death. Rationale: MVA continues to be a MAJOR cause of death for all ages groups. Also, remember NOT to choose answers that have "always", "never", "all" in them. Safety practice can reduce, but not COMPLETELY ELIMINATE, workplace risks.

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. Initiate use of a bed alarm. Administer the client's sedative as ordered. Put up all four side rails on the bed.

Initiate use of a bed alarm. Rationale: Prevent clients from getting out of bed using the least restrictive method possible first. All four side rails and chemical restraints like sedatives are considered forms of restraints, they should be used as a last resort if the patient pay harm themselves or others.

A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. 60% of U.S. fire deaths occur in the home. Most fatal fires occur when people are cooking. Most people who die in fires die of smoke inhalation. Over 1/3 of fire deaths occur in a home without a smoke detector. Fires are more likely to occur in homes without electricity or gas. More fires occur in homes occupied by single parents.

Most people who die in fires die of smoke inhalation., Over 1/3 of fire deaths occur in a home without a smoke detector., Fires are more likely to occur in homes without electricity or gas. Rationale: 85% of fires occur at home (60% too low), Most people who die of smoke inhalation die because they are sleeping not cooking, more smoke inhalation > burns. People without electricity or gas may have wood stoves, or fireplaces might be the only source of heat and they leave it on.

The nurse begins a shift and finds that the wrong medication has been administered to a client. After completing a safety event report, what should the nurse do next? File the safety event report in the appropriate file and document in the nurse's notes the date and time that it was filed. Make a copy of the safety event report for the client. Place the safety event report in the client's medical record for future reference. Submit the safety report to the appropriate department within the facility so that it can be reviewed.

Submit the safety report to the appropriate department within the facility so that it can be reviewed. Rationale: -Don't give incident reports to clients or chart it, give it to department in order for the institution to learn from the experience.

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? 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. 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. Sleeping pills = chemical restraint

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client?

The client will not experience a fall and remains free of injury. Rationale: Consider various factors and the environment that affect the client's safety and formulate expected outcomes for each situation. Some expected outcomes for clients that promote safety and prevent fall include: -Demonstrate safety measures to prevent falls -Remain free of injury during hospitalization

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury 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? 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. Rationale: Never events = cost of care will NOT be paid by CMS, but by the hospital.

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. Rationale: Unintentional injury that compromises safety in a health care agency needs a safety event report (incident report). Complete this after the incident and is responsible for recording it and the effect on the client in the medical record. The safety event report is NOT a part of the medical record and should not be mentioned in the documentation.

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. Rationale: Unintentional injury/incident that compromises safety in a health care agency needs a safety event report (incident report). -These safety event/incident reports do NOT need to be part of the medical record of patients and should not be reported in documentation. -HCP does not fill out these forms unless they were witnesses -No opinions just factual information

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? The nurse should notify the primary care physician about the bruises. The nurse should contact the facility's social services department. The nurse should question the client about the source of the bruises. The nurse should request permission from the client to photograph the bruises.

The nurse should question the client about the source of the bruises. Rationale: The first thing you should do is assess and question the source of the bruises. If the nurse feels like there is a potential abuse situation, then the nurse needs to report it.

A client's surgical wound dehisced when a nurse removed the staples before a health care provider order 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 orders will be reviewed. The nurse will be disciplined by an impartial review board. The nurse will be sued by the hospital for malpractice

The nurse will be found to have committed a human error. Systems around the documentation of orders will be reviewed. Rationale: No malice (intentional recklessness) or failing to realize the gravity of an action (at risk behavior). Systemic factors must be examined.

After performing neuro checks every 2 hours after an ischemic stroke, the nurse determines the client's neurological status is deterioriating. Which nursing action best prevents an adverse outcome in this client's care? initiating rehabilitation as soon as possible arranging for STAT computed tomography of the client's head documenting any changes in the client's status in a detailed and timely manner assessing the client's neurological status more frequently than ordered

assessing the client's neurological status more frequently than ordered Rationale: Assessing a patient more often can prevent adverse outcomes.

A nurse on a medical unit recognizes the need to demonstrate Quality and Safety Education for Nurses (QSEN) competencies in clinical practice. Which action best demonstrates the skills necessary to meet the QSEN competency of safety? filling out an incident report accurately after a client went missing from the unit appreciating the relationship between continuing education and client safety understanding the functions of a new automated intravenous pump that has been introduced to the unit valuing the contributions of clients and their families who suggest possible improvements in care

filling out an incident report accurately after a client went missing from the unit. Rationale: "Valuing" and "appreciating" = attitude, "understanding" is knowledge. While filling out an incident report is a SKILL that aligns with the QSEN competency of safety.

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 Rationale: (ugh this was my first choice), cooking causes the MOST residential fires. MOST fire deaths occur in the home just fyi

The nurses on a critical care unit can utilize the safety strategy of redundancy by: having two nurses independently check the dosage of high-risk medications. ensuring the antidotes are readily available for certain high-risk medications. introducing equipment that makes it more difficult for a nurse to commit an error. introducing a brief waiting period between the time that a medication is ordered and the time that it is administered.

having two nurses independently check the dosage of high-risk medications. Rationale: Successive checks for high risk procedures or meds add needed safety redundancy. Equipment that makes it difficult to make errors is an example of mistake-proofing.

The nurse is conducting a home care visit for a new mother who delivered a baby 3 days ago. Which finding within the home requires immediate nursing intervention? hot water heater thermostat set at 130 degrees F (54.4 degrees C) electrical outlets have covers over them one fire extinguisher is noted in the kitchen infant's sleepwear is made from flame-resistant fabrics

hot water heater thermostat set at 130 degrees F (54.4 degrees C) Rationale: Hot water heater thermostat is set abover 120 degrees which can burn the infant's skin.

The nurse is caring for a client who has been repetitively pulled at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered? temporary application of devices that reduce the client's ability to move arms providing a sleep agent to help the client rest instead of pulling IV lines and the catheter delegating to the unlicensed assistive personnel (UAP) to sit with the client administration of an antipsychotic agent to alter the client's behavior

temporary application of devices that reduce the client's ability to move arms Rationale: After diversion behaviors and chemical (drug) restraints have failed, the nurse should use temp devices to reduce the client's ability to move arms