Chapter 21. Promoting Safety My Nursing Test Banks

Chapter 21. Promoting Safety

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis?

1)

Risk for Falls

2)

Risk for Ineffective Airway Clearance (choking)

3)

Risk for Poisoning

4)

Risk for Suffocation (drowning)

____ 2. A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be slightly unsteady. What assessment should the nurse perform next?

1)

Perform the Get Up and Go Test.

2)

Ask the patient if he has fallen in the past year.

3)

Refer the patient for a comprehensive fall evaluation.

4)

Administer the Timed Up and Go Test.

____ 3. The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best?

1)

Continue to monitor the pump to see if the crack worsens.

2)

Place the pump back on the utility room shelf.

3)

A small crack poses no danger so continue using the pump.

4)

Clearly label the pump and send it for repair.

____ 4. A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first?

1)

Apply a cloth vest restraint.

2)

Encourage a family member to stay with the patient.

3)

Administer lorazepam (an antianxiety medication).

4)

Keep the patients bed side rails up.

____ 5. Despite less restrictive interventions, a patients behavior escalates, requiring emergency application of restraints. Which of the following must the nurse do in this situation?

1)

Obtain a physicians order before applying restraints.

2)

Monitor the patients status every 4 hours while restrained.

3)

Release the restraints and check circulation every hour.

4)

Continually reevaluate the patients need for restraint.

____ 6. A patient has received a radiation implant. The patient is weak and needs help even to turn in bed. Which action should the nurse take when caring for this patient?

1)

Avoid giving the patient a complete bed bath.

2)

Limit the amount of time spent with the patient.

3)

Allow extra time for the patient to express feelings.

4)

Do not allow anyone to visit the patient.

____ 7. A child is brought to the emergency department after swallowing liquid cleanser. He is awake and alert and able to swallow. Which action should the nurse take first?

1)

Administer a dose of syrup of ipecac.

2)

Administer activated charcoal immediately.

3)

Give water to the child immediately.

4)

Call the nearest poison control center.

____ 8. A nurse is teaching a group of mothers about first aid. Should poison come in contact with their childs clothing and skin, which action should the nurse instruct the mothers to take first?

1)

Remove the contaminated clothing immediately.

2)

Flood the contaminated area with lukewarm water.

3)

Wash the contaminated area with soap and water and rinse.

4)

Call the nearest poison control center immediately.

____ 9. Which of the following instructions is most important for the nurse to include when teaching a mother of a 3-year-old about protecting her child against accidental poisoning?

1)

Store medications on countertops out of the childs reach.

2)

Purchase medication in child-resistant containers

3)

Take medications in front of the child, and explain that they are for adults only.

4)

Never leave the child unattended around medications or cleaning solutions.

____ 10. A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associated with mercury inhalation?

1)

Chest pain, pneumonitis, and inflammation of the mouth

2)

Intestinal obstruction and numbness of the hands

3)

Hypotension, oliguria, and tingling of the feet

4)

Tachycardia, hematuria, and diaphoresis

____ 11. Which aspect of restraint use can the nurse delegate to the nursing assistive personnel?

1)

Assessing the patients status

2)

Determining the need for restraint

3)

Evaluating the patients response to restraints

4)

Applying and removing the restraints

____ 12. The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first?

1)

Encourage the child to continue coughing.

2)

Deliver upward abdominal thrusts with a fisted hand.

3)

Deliver five rapid back blows between the shoulder blades.

4)

Perform a blind finger sweep of the childs mouth.

____ 13. Which is the most commonly reported incident in hospitals?

1)

Equipment malfunction

2)

Patient falls

3)

Laboratory specimen errors

4)

Treatment delays

____ 14. The Joint Commissions national Speak Up campaign encourages patients to become active and informed participants on the healthcare team. The goal is to:

1)

prevent healthcare errors.

2)

help control the cost of healthcare.

3)

reduce the number of automobile accidents.

4)

provide a forum for people with no health insurance.

____ 15. A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse are advisable?

1)

Reassure the patient by entering the room alone.

2)

Ask the patient if he is carrying any weapons.

3)

Stay between the patient and the door; keep the door open.

4)

Make eye contact while stating firmly I will not tolerate cursing and threats.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. Which point(s) should the nurse include when teaching safety precautions to a mother of a toddler? Select all that apply.

1)

Make sure the child sleeps on his back at night.

2)

Keep the telephone number of the poison control center accessible.

3)

Use a front-facing car seat placed in the back seat of the car.

4)

Keep syrup of ipecac on hand in case of accidental poisoning.

____ 2. During a thermometer exchange program at a local hospital, a person drops a mercury thermometer on the floor. Assume the nurse has been trained in cleanup of such a spill. Select all that are appropriate. How should the nurse intervene?

1)

Using gloves and a paper towel, place the mercury in a plastic bag, and dispose of it.

2)

Notify the hazardous material management team immediately.

3)

Evacuate the area immediately.

4)

After putting on a gown, gloves, and a mask, clean up the mercury.

5)

Wash her hands well after removing the spill.

6)

Ventilate the area well for several days.

Other

1. Rank the following leading causes of accidental death in the United States according to their frequency of occurrence. Rank as 1 the one that occurs most frequently; rank as 4 the one that occurs least frequently.

A. Motor vehicle accidents

B. Falls

C. Suffocation

D. Poisonings

2. When the nurse walks into the patients room, she notices fire coming from the patients trash can. Rank the following actions in the order they should be performed by the nurse. 1 should be done first; 4 should be last.

A. Activate the fire alarm.

B. Move the patient out of the room.

C. Close all doors and windows.

D. Put out the fire using the proper extinguisher.

Chapter 21. Promoting Safety

Answer Section

MULTIPLE CHOICE

1. ANS: 1

Loss of muscle strength and joint mobility place older adults at risk for falls. Choking, drowning, and ingesting poisons are primary safety concerns for infants and toddlers.

PTS: 1 DIF: Moderate REF: V1, p. 437

KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall

2. ANS: 3

If a patients gait or balance is unsteady, the nurse should question the patient for a history of falls. If the patient reports a single fall, the nurse should do the Get Up and Go Test. If the patient has difficulty with that test, or is unsteady with it, the nurse should perform a follow-up assessment of gait and balance by having the person close the eyes for a few seconds wile standing in place; stand with eyes closed while nurse pushes gently on the sternum; walk, stop, turn around, return to the chair, and sit in the chair without using his arms for support. Physicians and advanced practitioners perform the Timed Up and Go Test; it is recommended annually for patients 65 years or older.

PTS: 1 DIF: Difficult REF: V1, p. 447

KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application

3. ANS: 4

Whenever an electrical safety hazard is suspected or visible, the nurse should label the malfunctioning equipment and send it for repair or inspection. Continuing to use the IV infusion pump or any other equipment places the patient at risk for injury. Placing the pump back on the shelf places other healthcare team members at risk for electrical injury if they attempt to use the equipment.

PTS: 1 DIF: Easy REF: V1, p. 458

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

4. ANS: 2

The nurse should use one-to-one supervision with this patient to maintain the patients safety. This can be accomplished by encouraging a family member to stay with the patient. Restraints should be used only when all other less restrictive measures have failed and are absolutely necessary to prevent injury to the patient. Restraints have been shown to jeopardize patient safety. It is not appropriate to administer sedation for the purpose of keeping the patient in bed; this is a form of restraint. Keeping the side rails up is also a form of restraint and increases the risk for falling.

PTS: 1 DIF: Moderate REF: V1, p. 443 | V1, p. 461

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

5. ANS: 4

The patient must be continually monitored, and the need for restraint must be continually reevaluated. As a rule, a medical order should be obtained before applying restraints. However, in an emergency, the nurse is permitted to apply restraints for behavior management, but a physician or advanced practice nurse must then evaluate the patient within 1 hour of restraint application. The order for restraint must be renewed daily. The restraints must be released at least every 2 hours, and circulation must be checked.

PTS: 1 DIF: Difficult REF: V1, pp. 443-444 | V1, p. 458 | V2, p. 374

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

6. ANS: 2

When caring for a patient with a radiation implant, the nurse should organize nursing care to limit the amount of time with the patient to limit radiation exposure. The nurse must meet the patients personal hygiene needs by bathing the patient, if necessary. The nurse should encourage the patient to express her feelings; however she should limit her contact with the patient. Pregnant women should not visit the patient; however, others may visit as long as they uphold the principles of time, distance, and shielding.

PTS: 1 DIF: Moderate REF: V1, p. 445

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

7. ANS: 3

If the child is awake and able to swallow, and the child has swallowed a household chemical, give one-half glassful of water immediately. After giving the water, call the poison control center. The American Academy of Pediatrics does not advise giving syrup of ipecac. Emergency departments have stopped using ipecac in favor of activated charcoal, which binds to poison in the stomach and prevents it from entering the bloodstream. Continued vomiting caused by syrup of ipecac may later result in the child being unable to tolerate activated charcoal or other poison treatments. No one can tell how much a child vomits, and therefore, no one would know if all the poison was eliminated from the stomach. There is also potential for misuse by bulimics. The poison control center may recommend activated charcoal, depending upon the agent ingested.

PTS: 1 DIF: Difficult REF: V1, p. 451

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

8. ANS: 1

The nurse should tell the mother to first remove the contaminated clothing as quickly as possible. Then, flood the contaminated area with lukewarm water. Next, gently wash the area with soap and water and rinse. Have someone call the poison control center. It does not need to be a local poison control center. Additionally, it is most important to remove contact between the skin and poison before doing anything.

PTS: 1 DIF: Moderate REF: V1, p. 451

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

9. ANS: 4

The nurse should instruct the mother to avoid leaving her child unattended around medications or cleaners even for a moment. Medications should never be stored on kitchen counters or bathroom surfaces because children love to explore and climb and can get into them. The nurse should explain that medications should not be taken in front of the child because children imitate adult behavior. The nurse should reinforce that although child-resistant containers are a deterrent, they are not foolproof because many toddlers and preschoolers can open them.

PTS: 1 DIF: Moderate REF: V1, p. 450

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

10. ANS: 1

Acute adverse effects of mercury inhalation include respiratory damage, wakefulness, muscle weakness, anorexia, headache, ringing in the ears, chest pain, inflammation of mouth, and pneumonitis. Chronic effects include numbness or tingling of the hands, lips, and feet, and personality changes. Intestinal obstruction is an acute effect of mercury ingestion. Hypotension, oliguria, hematuria, and diaphoresis are not acute effects of mercury inhalation.

PTS: 1 DIF: Difficult REF: V1, p. 444

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

11. ANS: 4

The nurse can delegate applying and removing the restraints, skin care, and checking for skin breakdown. The nurse responsible for care of the patient must assess the patients need for restraint and the patients status and must evaluate the patients response to restraints.

PTS: 1 DIF: Moderate REF: V1, p. 462 | V2, p. 370

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

12. ANS: 1

If the nurse suspects aspiration in a child who is coughing vigorously, the nurse should encourage the child to continue coughing. If coughing weakens, the nurse should perform the choking maneuver by administering five rapid back blows alternated with five upward thrusts to the upper abdomen with a fisted hand, just below the rib cage. A blind finger sweep should never be performed because it could push the foreign object into the airway.

PTS: 1 DIF: Moderate

REF: V1, p. 450; Chapter 21 ESG Box 21-4, Rescue Maneuver for Choking: Adult or Child over 12 Months

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

13. ANS: 2

Patient falls are by far the most common incident reported in hospitals and long-term care facilities. Although equipment (e.g., infusion pump) malfunctions, missed or incorrectly identified laboratory specimen collection, and treatment delays sometimes occur, they do not occur as frequently as patient falls.

PTS: 1 DIF: Moderate REF: V1, p. 442

KEY: Client need: SECE | Cognitive level: Comprehension

14. ANS: 1

The Joint Commission, with the Centers for Medicare and Medicaid Services, urges patients to take a role in preventing healthcare errors by becoming active, involved, and informed participants on the healthcare team. A reduction in healthcare errors could indirectly reduce healthcare costs, but this is not the intent of the campaign. The campaign has nothing to do with automobile accidents, as might be deduced from the fact that the Joint Commission and Medicare/Medicaid regulate healthcare agencies. The campaign has little relationship to insurance, other than to encourage clients to speak up, ask questions, and know their rights.

PTS: 1 DIF: Difficult REF: V1, pp. 448-449

KEY: Client need: SECE | Cognitive level: Comprehension

15. ANS: 3

The nurse should keep the door open and position herself so that the patient cannot block her exit from the room. The nurse should not enter a room alone with an angry patient. The progression to physical violence is first anxiety, then verbal aggression, and finally physical aggression. The nurses first priority in this situation is her own safety and the safety of others in the environment. The object is to relieve the patients anxiety and not respond to anger with anger. Questioning about weapons, or being firm and defending against verbal aggression will likely provoke even more anger from the patient. The nurse must be calm and reassuring.

PTS: 1 DIF: Difficult REF: V1, p. 462

KEY: Client need: PSI | Cognitive level: Application

MULTIPLE RESPONSE

1. ANS: 2, 3

The nurse should teach the mother of a toddler to keep the telephone number of the poison control center accessible because toddlers are at risk for accidental poisonings. Toddlers should also have front-facing car seats. Syrup of ipecac is no longer recommended to induce emesis after poisonings. Infants, not toddlers, should sleep on their backs to prevent sudden infant death syndrome.

PTS: 1 DIF: Moderate REF: V1, p. 437 | V1, p. 450 | V1, p. 455

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

2. ANS: 1, 5, 6

The nurse should put on gloves and use a paper towel to pick up the mercury. Then place the mercury, broken thermometer, and soiled paper towel into a plastic bag along with the gloves. Next, the nurse should dispose of the plastic bag, wash her hands, and ventilate the area well. It is not necessary to notify the hazardous material management team or evacuate the area for a spill this small, unless agency policy actually mandates that. The nurse does not need to put on a gown and mask to dispose of the mercury.

PTS: 1 DIF: Moderate REF: V1, p. 462

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

OTHER

1. ANS:

A, D, B, C

Motor vehicle accidents are the leading cause of accidental death in the United States, followed by poisonings, falls, and suffocation.

PTS: 1 DIF: Easy REF: V1, p. 436

KEY: Client need: SECE | Cognitive level: Comprehension

2. ANS:

B, A, C, D

The nurse should first move the patient out of the room, then activate the alarm, close all doors and windows and turn off oxygen valves, and use the proper extinguisher to put out the fire.

PTS: 1 DIF: Difficult REF: V1, p. 460

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

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