Chapter 20: Patient Environment and Safety My Nursing Test Banks

Chapter 20: Patient Environment and Safety

Test Bank

MULTIPLE CHOICE

1. An elderly patient who is unable to get out of bed complains that the room is too cold because of the air conditioning and asks the nurse to open the window. The nurses best reply is:

a.

Certainly, that will let in warm air from outside and should make you warmer.

b.

The air conditioner is set to keep the most comfortable temperature in the room.

c.

Ill adjust the thermostat in your room and get a blanket for you.

d.

Agency policy prevents me from opening the window.

ANS: C

Older inactive people need a warmer environment because of their poor temperature regulation. Rooms should be kept at a comfortable 68 to 74 F. Most hospitals prohibit the opening of windows for safety reasons.

DIF: Cognitive Level: Application REF: p. 313 OBJ: Theory #1

TOP: Environment Management KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

2. An appropriate environmental nursing intervention for a patient with respiratory congestion is to:

a.

maintain the room temperature slightly cooler to decrease congestion.

b.

moisten the respiratory passages with the use of an air humidifier.

c.

order a large floor fan to make it easier to breathe.

d.

open the windows to encourage air circulation.

ANS: B

A very low humidity will dry respiratory passages. Vaporizers or humidifiers may be ordered for a patient with a respiratory condition. Small table fans may help some persons to breathe more easily.

DIF: Cognitive Level: Application REF: p. 314 OBJ: Clinical Practice #1

TOP: Environment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

3. The patient complains of an odor in his room that smells like something is rotting. The nurse makes an assessment of the room and:

a.

changes the linens, which are wrinkled and rumpled from 24-hour use.

b.

rinses out the emesis basin of used dry tissues.

c.

removes an old flower arrangement.

d.

heavily sprays room deodorant around the patients bed.

ANS: C

Odors in hospitals are frequently unpleasant. The odor from a deteriorating flower arrangement is offensive. The arrangement should be discarded in a container outside the patients room.

DIF: Cognitive Level: Analysis REF: p. 314, Box 20-1

OBJ: Theory #1 TOP: Environment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

4. A patient complains of not being able to sleep because of the noise in the hall at night. The nurse should:

a.

move the patient to the far end of the hall.

b.

ask the doctor for a sleeping medication for the patient.

c.

tell the patient to close the door.

d.

request that co-workers limit hallway conversations.

ANS: D

The main cause of noise is people. Encourage the staff to limit conversations in the hallway and speak in lowered voices.

DIF: Cognitive Level: Application REF: p. 314 OBJ: Theory #2

TOP: Environment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

5. The best way to maintain safety measures relative to helping a patient get into bed is to:

a.

set the bed height at the nurses waist level.

b.

make sure that the bed wheels are locked.

c.

place the bed against the wall.

d.

insist that the patient stay in bed.

ANS: B

The goal is to provide safety when getting a patient into or out of bed. Locking the wheels to the bed is one way to ensure this safety measure.

DIF: Cognitive Level: Application REF: p. 315 OBJ: Theory #4

TOP: Safety KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

6. When the nurse is making an occupied bed, back safety indicates that the nurse should initially:

a.

raise the bed to the proper working height before starting.

b.

encourage the patient to use the side rail to help turn side to side.

c.

keep one side rail up at all times to keep the patient from falling.

d.

complete the linen change on one side before moving to the other side.

ANS: A

Bringing the bed to height-appropriate working level can prevent a back injury. Although other options are part of the occupied bed skill, they are not directed at preventing back strain.

DIF: Cognitive Level: Application REF: p. 321, Box 20-2

OBJ: Clinical Practice #2 TOP: Safety

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

7. A patient has left-sided paralysis following a right-sided cerebrovascular accident (CVA). After completing a bed bath, the nurse should begin to change the sheets by:

a.

lowering both side rails and rolling the patient to the side of the bed.

b.

asking the patient to roll to his right and hold on to the side rail for support.

c.

positioning the patient in a supine position with both side rails raised.

d.

positioning the patient in a side-lying position on his left side with the near side rails raised.

ANS: D

Moving the patient to the left side-lying position provides safety for the patient and allows the patient to use his good (right) hand to hold the rail.

DIF: Cognitive Level: Analysis REF: p. 318, Skill 20-2

OBJ: Clinical Practice #2 TOP: Safety

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

8. An elderly patient is discharged home after hip surgery. The statement that indicates a family member understands discharge safety instructions given by the nurse is, I will:

a.

install grab bars in the bathroom for both the toilet and bathtub.

b.

put all personal items away to prevent my mother from dropping things.

c.

dim the lights at night to prevent wakefulness.

d.

ensure that my mother takes naps during the day to prevent tiredness.

ANS: A

Grab bars in the tub and at the toilet help the person with joint impairment to bathe and toilet safely. Using well-lit areas during the day and night-lights at night is helpful to avoid falls. Daytime napping may cause restlessness at night.

DIF: Cognitive Level: Analysis REF: p. 322, Box 20-3

OBJ: Theory #4 TOP: Safety KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

9. The nurse in a long-term facility who is making a fall assessment would identify the person most at risk for a fall to be a resident who:

a.

paces all day in the halls and sleeps well at night.

b.

had knee replacement surgery 2 days ago and wears a knee brace.

c.

had a stroke with right-sided weakness 2 weeks ago and is confused.

d.

uses a walker to ambulate both indoors and outdoors.

ANS: C

The most common factors predisposing a person to falls are impaired physical mobility, altered mental status, and unavailability of assistance.

DIF: Cognitive Level: Analysis REF: p. 321, Box 20-2

OBJ: Theory #4 TOP: Safety KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: safety and infection control

10. A patient who has right-sided weakness following a stroke is admitted to a long-term care facility and exhibits increasing wandering and inability for self-care. To protect the patient from the most frequent cause of injury among the elderly, the nurses most efficient intervention would be:

a.

provide a night-light in the bathroom.

b.

keep pathways clear of paper, shoes, and equipment.

c.

apply a personal alarm.

d.

provide hip protectors.

ANS: C

Because falls are the most common accidents among residents, the provision of a personal alarm to sound when the person attempts to get out of bed is the most efficient intervention. Keeping the pathways clear, provision of adequate light, and provision of hip protectors are all safety oriented but do not prevent falls.

DIF: Cognitive Level: Analysis REF: p. 322, Box 20-3

OBJ: Theory #3 TOP: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

11. A diabetic patient has chronic peripheral vascular disease, which results in edema and poor circulation to her feet. She constantly complains of cold legs. The best nursing action is to provide:

a.

a heating pad and place it under the patients feet.

b.

an electric blanket to increase warmth to legs at night.

c.

a hot shower to increase circulation to legs.

d.

additional blankets and encourage the use of warm bed socks.

ANS: D

Extra blankets and bed socks will reduce the sense of cold. A person with diabetes or impaired circulation is more easily burned than a person in good health.

DIF: Cognitive Level: Application REF: p. 323 OBJ: Theory #1

TOP: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

12. An agitated resident who is seated in his wheelchair calls the nurse because the bed linens are smoldering. After moving the patient to the hall, the nurse should:

a.

close the door to the room to confine the fire.

b.

assess the patient for burns.

c.

extinguish the flames with an appropriate extinguisher.

d.

activate the fire alarm system immediately.

ANS: D

RACE is used as an acronym to respond to fire. RACE represents Rescuing the patient from immediate danger, Activating the fire alarm system, Containing the fire by closing doors and windows, and Extinguishing the flames with an appropriate extinguisher.

DIF: Cognitive Level: Application REF: p. 323 OBJ: Theory #4

TOP: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

13. When caring for a patient with acute radiation sickness (ARS) after an accident at an atomic power plant, the nurse should:

a.

wear a paper gown and boots, gloves, and a mask.

b.

stay in the room and talk to the patient to alleviate anxiety.

c.

decrease the amount of time spent in the room.

d.

wear a chemical mask with a filtered respirator.

ANS: A

For prolonged periods in caring for a patient with ARS, the nurse should use the barrier protection of gown, boots, a mask, and gloves.

DIF: Cognitive Level: Application REF: p. 325 OBJ: Theory #1

TOP: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

14. There is evidence that a resident in a home care environment might have accidentally ingested gasoline left by the gardeners. The nurse should first:

a.

call the family members to notify them of the incident.

b.

call the poison control center and describe the situation.

c.

induce the patient to vomit.

d.

place the gasoline can in a safe place.

ANS: B

If a nurse suspects gasoline poisoning, it is important to call the poison control center to obtain further instructions. It is also important to prevent vomiting, because this may cause respiratory problems.

DIF: Cognitive Level: Application REF: p. 326 OBJ: Clinical Practice #1

TOP: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

15. A nursing assistant on the day shift reports that he has raised the bed rails to keep an agitated patient from climbing out of bed. The nurses best response to this information is:

a.

Good idea. Be sure to check on the patient every hour to assess the patients comfort.

b.

A vest protective device will work better; put one on the patient, please.

c.

The rails wont prevent falling; bring the patient out to sit by the nurses station where we can watch her.

d.

Youll need to check the patient every 15 minutes and reorient the patient as to why the rails are up.

ANS: C

Seating the patient close to the nurses station will allow the nurse to check on the patient frequently. The nurse needs to get an order for a vest restraint.

DIF: Cognitive Level: Application REF: p. 322, Box 20-3

OBJ: Clinical Practice #6 TOP: Safety

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment

16. A patient is agitated and confused and keeps getting out of bed and needs to be observed constantly. The best initial nursing intervention is to:

a.

have a family member or friend sit with the patient.

b.

obtain an order for a sedative from the physician.

c.

instruct the nurses aide to apply a vest restraint.

d.

make sure the side rails are up and close the door.

ANS: A

Local and federal laws prohibit the use of physical and chemical restraints except those authorized by a physician. Health care workers are encouraged to find other alternatives such as asking a family member to supervise the patient before resorting to the use of protective devices.

DIF: Cognitive Level: Application REF: p. 328, Skill 20-3

OBJ: Theory #1 TOP: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

17. The doctor has written an order to place a resident in the nursing home in a vest protective device. It is the nurses responsibility to:

a.

check with the nursing supervisor about the legality of the order.

b.

remove the device every 2 hours and change the patients position.

c.

remove the device every 4 hours to toilet the patient.

d.

apply the device loosely to prevent circulation impairment.

ANS: B

Changing position helps prevent other complications such as skin decubiti.

DIF: Cognitive Level: Comprehension REF: p. 327, Box 20-5

OBJ: Theory #6 TOP: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

18. The physician orders wrist restraints for an agitated patient. To safely use this protective device, the nurse:

a.

checks that circulation is not impaired by evaluating color, warmth, and pulses distal to the device.

b.

secures the ties of the device to the side rails of the bed to allow for easy access by the nurse.

c.

draws the restraint tightly to prevent the patients hands from slipping out.

d.

uses a knot that is not easily undone for patient security.

ANS: A

Checking for signs indicating that circulation has been impaired or skin abraded or for evidence of nerve impairment is part of the nurses responsibility in upholding the principles of the use of protective devices.

DIF: Cognitive Level: Application REF: p. 327, Protective Devices

OBJ: Theory #6 TOP: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

19. The home health nurse assessing the home for safety hazards notes a hazard that should be remedied is:

a.

an extension cord lying across the floor.

b.

non-skid bath mats on the bathroom floor and in the shower.

c.

night-lights high on the wall in the bathroom.

d.

lack of scatter rugs on the wooden floor.

ANS: A

Extension cords pose a hazard for falls. The rest of the items assist in the prevention of falls.

DIF: Cognitive Level: Application REF: p. 322, Box 20-3

OBJ: Theory #1 TOP: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

20. A resident is confused and teary. She is threatening to leave the facility to return home. The nurse should:

a.

call her family immediately and notify them of the problem.

b.

have the nurses aide place a vest restraint on the patient.

c.

call the doctor immediately and get an order for a protective device.

d.

talk to the patient and attempt to determine the cause of the problem.

ANS: D

Restraints may not be used without an order or to punish or discipline a patient. Talking to the patient is an excellent strategy to determine the cause of the problem. Medications may also cause mood alterations.

DIF: Cognitive Level: Analysis REF: p. 328, Skill 20-3

OBJ: Theory #6 TOP: Alternative to Restraints

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

21. The nurse clarifies to the worried family that the guiding principle for using protective devices is:

a.

to use the least amount of immobilization needed for the situation.

b.

to use only immobilization techniques necessary to keep the patient safe.

c.

that protective devices are mandated for behavioral use only.

d.

that protective devices must be applied by qualified personnel.

ANS: A

The principle is derived from local and federal laws and endorsed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which supports restraints only as a last resort. This is because of previous misuse and abuse of these devices by health care personnel.

DIF: Cognitive Level: Knowledge REF: p. 327, Box 20-5

OBJ: Theory #6 TOP: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: reduction of risk

22. Material safety data sheets (MSDS) are required by the Occupational Safety and Health Administration (OSHA). The nurse must:

a.

have a copy of all MSDS on the unit to safely handle biohazards.

b.

know the location of the MSDS and comply with their guidelines.

c.

not handle biohazards identified in the MSDS.

d.

keep the MSDS confidential and not discuss them outside the agency.

ANS: B

MSDS are consulted for recommended methods of storage, labeling, handling spills, and disposal of biohazards.

DIF: Cognitive Level: Knowledge REF: p. 324 OBJ: Clinical Practice #3

TOP: Environment Management KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

23. A nurse is instructing a nursing student about restraint use. The nurse recognizes the need for further instruction when the nursing student states, I will:

a.

tie the restraints to the side rails to ensure the restraints are secure.

b.

use a half-bow knot to secure the restraints to the bed frame.

c.

check the area distal to the restraints every 15 to 30 minutes.

d.

observe for signs of adequate circulation, including distal pulses.

ANS: A

Restraint ties should be secured to an immovable part of the bed frame. They should not be tied to the side rails because lowering the rails may cause the device to be pulled too tightly around the patient or cause strain on a joint of an immobilized extremity. A half-bow knot should be used to secure the device to the bed frame or chair. The area distal to the restraint should be checked every 15 to 30 minutes and should be observed for signs of adequate circulation, including pulses distal to the device.

DIF: Cognitive Level: Application REF: p. 328, Skill 20-3

OBJ: Theory #6 TOP: Restraints KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: basic care and comfort

MULTIPLE RESPONSE

24. The certified nursing assistant (CNA) places a confused, weak patient in a wheelchair and applies a vest protective device. The nurse should instruct the CNA to: (Select all that apply.)

a.

secure the ties in the front to prevent the patient from falling.

b.

secure the ties in the back to prevent the patient from falling.

c.

use a double knot to prevent the patient from undoing the tie.

d.

use a half-bow knot to secure the device to a chair.

e.

provide passive range of motion to the upper extremities as needed.

ANS: B, D, E

Placing the ties under the armrests and securing at the back will keep the patient from sliding. The half-bow knot makes it difficult for the patient but easy for the health care worker to undo.

DIF: Cognitive Level: Application REF: p. 328, Skill 20-3

OBJ: Clinical Practice #6 TOP: Safety

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

25. Legal implications for using a protective device require thorough documentation and require that the nurse include: (Select all that apply.)

a.

alternative methods and actions used.

b.

medications that the patient is taking.

c.

teaching done for patient and family.

d.

the patients medical diagnosis.

e.

type of device and placement.

ANS: A, C, E

The nurse should document alternative methods and actions taken before placing the device, the teaching done for both patient and family, and the type of device used and where it was placed. Remember, if it is not documented, it was not done.

DIF: Cognitive Level: Knowledge REF: p. 328, Skill 20-3

OBJ: Theory #7 TOP: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk

26. Each resident admitted must have a fall risk assessment performed so that appropriate actions to prevent falls can be included in the nursing care plan. The items are considered when doing a fall risk assessment on a newly admitted resident include: (Select all that apply.)

a.

gender.

b.

age.

c.

weight.

d.

medications.

e.

balance.

ANS: B, D, E

The common factors that predispose a person to falls may include age, the type of medications the resident is taking, and physical mobility.

DIF: Cognitive Level: Knowledge REF: p. 321, Figure 20-3

OBJ: Theory #1 TOP: Safety KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: reduction of risk

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