Chapter 28: Safety My Nursing Test Banks

Chapter 28: Safety

Potter: Essentials for Nursing Practice, 8th Edition

MULTIPLE CHOICE

1.The patient has recently moved into a newly renovated home in the inner city. The patient is being seen in the clinic for complaints of ongoing headaches, nausea, dizziness and fatigue. The symptoms started shortly after moving into the new home. As the nurse gathers information, which of the following questions would be most appropriate to ask the patient?

a.

Have you changed the battery in your smoke alarm recently?

b.

Have you changed your diet since moving?

c.

What type of furnace do you have?

d.

When was the last time your house was painted?

ANS: C

A furnace, stove, or fireplace that is not properly vented introduces carbon monoxide into the environment. This gas binds strongly with hemoglobin; preventing the formation of oxyhemoglobin and thus reducing the supply of oxygen delivered to the tissues. Low concentrations cause nausea, dizziness, headache, and fatigue. The importance of having a proper working smoke detector will decrease the chance of smoke inhalation and potential death owing to a fire but does not produce the symptoms listed. A balanced diet and proper storage of food is essential to decrease the chance of infection to the gastrointestinal system but does not produce the symptoms listed. Painting would not produce the symptoms listed even if the paint is old and contains lead as it must be ingested.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:721

OBJ: Describe methods to evaluate interventions designed to maintain or promote safety.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

2.The registered nurse from the home health agency is performing an initial assessment on a 72-year-old patient who was released from a nursing home. The patient had been admitted to the nursing home for therapy after surgery for repair of a fractured left hip. During a survey of the home environment, which finding would cause the nurse to intervene?

a.

Bedside lamp plugged into the wall outlet behind the bed

b.

Handrail on one side of the stairs only

c.

Throw rugs in the bedroom

d.

No handrail near the toilet

ANS: C

Common physical hazards that lead to falls in the home include inadequate lighting, barriers along normal walking paths and stairways, and a lack of safety devices. All other answers do not indicate a safety risk to the home.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:721 | 722 | 726

OBJ: Describe methods to evaluate interventions designed to maintain or promote safety.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

3.Of the following, who is most at risk for accidental poisoning?

a.

Supervised 16-month-old toddler eating dry cereal in the highchair

b.

Unsupervised 2-month-old infant left near a closed bottle of prescription medication

c.

Unsupervised 4-year-old child playing dress-up with mothers makeup

d.

Supervised 6-year-old child playing with watercolor paints

ANS: C

In the home, accidental poisoning is a greater risk for the toddler, preschooler, and young school-age child, who often ingest household cleaning solutions, medications, or personal hygiene products. Two of the responses have the word supervised in the response, which makes them incorrect for an accidental poisoning. The response which has the childs age of 2 months decreases the chance of accidental poisoning due to lack of coordination and dexterity (a 2-month-old cannot open a closed medication bottle).

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:722

OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

4.A nursing student is volunteering with a local agency to help prepare the community for a potential bioterrorist attack. On which of the following threats would be the nursing students primary focus?

a.

Hurricane

b.

Earthquake

c.

Anthrax

d.

Tornado

ANS: C

A new potential environmental health threat is the possibility of a bioterrorist attack. Threats of this type come in the form of biological, chemical, and radiological attacks. Bioterrorism, or the use of biological agents to create fear and threat, is the most likely form of a terrorist attack to occur. The other responses (hurricane, earthquake, and tornado) are classified as natural disasters.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:723

OBJescribe environmental hazards that pose risks to patient safety.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

5.All hospital employees are concerned about the safety of patients in the hospital, especially regarding the transmission of pathogens. What is the most common means of transmission of pathogens in this environment?

a.

Contaminated blood products

b.

Enteric transmission

c.

Insufficient hand hygiene

d.

Aerosols

ANS: C

A pathogen is any microorganism capable of producing an illness. The most common means of transmission of pathogens is by the hands. Pathogens are also transmitted through a humans blood and body fluids and by insects (e.g., mosquitoes carrying malaria) and rodents. Although the other responses could spread pathogens, the most correct answer and most common method is insufficient hand hygiene.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:723

OBJescribe environmental hazards that pose risks to patient safety.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

6.A registered nurse works in a small rural health clinic. During a routine well baby visit, a new mother questions the need to have her infant immunized. Which of the following is the best explanation for why it is recommended that her child receive immunizations?

a.

Immunization increases resistance to an infectious disease.

b.

It provides a small amount of a live, strong organism to protect against disease.

c.

Immunization will definitely keep your child well.

d.

It will provide active immunity by providing antibodies to your child.

ANS: A

Immunization is the process by which resistance to an infectious disease is produced or increased. A weakened or dead organism and modified toxins from the organism is injected into the body, not a live, strong organism. Immunizations do not definitely keep a child well. Passive immunity occurs when antibodies produced by other people or animals are introduced into a persons bloodstream, whereas active immunity is from a weakened or dead organisms or modified toxins from the organism.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:723

OBJ: Describe methods to evaluate interventions designed to maintain or promote safety.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

7.A nurse is giving anticipatory guidance to the mother of a 10-month-old child. The nurse is focusing on providing a safe environment for the child. Which of the following is the best statement regarding childhood safety?

a.

The car seat should be placed in a forward-facing position.

b.

The majority of deaths in children between the ages of 1 and 3 years old are caused by contagious diseases.

c.

Injuries are a major cause of death during infancy, especially for children 6 to 12 months old.

d.

Measles causes more deaths in children younger than 5 years old than all other diseases combined.

ANS: C

Injuries, not contagious diseases, are a major cause of death during infancy, especially for children 6 to 12 months old. The leading causes of injury to infants are falls, ingestion injuries (poison, foreign body ingestion, and medication), and burns. Aspiration often occurs from the ingestion of foreign material such as small toys and food items. The question is asking for a safe environment assessment and childhood safety; measles is an illness/disease caused by a pathogen and does not relate to providing a safe environment or information about childhood safety. All infants and toddlers should ride in a rear-facing car safety seat until they are 2 years of age or until they reach the highest weight or height allowed by the manufacturer of the car seat.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:723

OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

8.The parent of a 13-year-old boy is concerned because the teenager wants to hang out with friends all the time and has stated that he wants to get his ear pierced because all his friends have piercings. What is the best response from the nurse?

a.

I think you need to seek counseling for your son.

b.

I think this is just a phase that will quickly pass.

c.

Your son needs to find new friends.

d.

Your sons behavior is normal; he is trying to assert his independence.

ANS: D

As children enter adolescence, they develop greater independence and a sense of identity. The adolescent begins to separate emotionally from the family, and the peer group begins to have a stronger influence. To relieve the tensions associated with the physical and psychosocial changes, as well as peer pressure, adolescents often engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs. This increases the risk for accidents such as drowning and motor vehicle accidents. Counseling and finding new friends are not needed because the boy is demonstrating normal signs of development. Adolescence does not quickly pass.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:724

OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

9.A 16-year-old patient is being seen in the emergency department (ED) after being involved in a minor motor vehicle accident. The guardian has voiced that the patient has been spending more time in his or her room, has difficulties getting along with friends, and has declining grades over the past 3 months. The patient seems distant and angry all the time. Which of the following topics is most important for the nurse to discuss with the guardian?

a.

Accident prevention measures

b.

Enrolling the patient in a defensive driving course

c.

The possibility of substance abuse

d.

The importance of automobile insurance

ANS: C

To assess for possible substance abuse, have parents look for environmental and psychosocial clues. Environmental clues include the presence of drug-oriented magazines, beer and liquor bottles, drug paraphernalia, blood spots on clothing, and the continual wearing of long-sleeved shirts in hot weather and dark glasses indoors. Psychosocial clues include failing grades, change in dress, increased absenteeism from school, isolation, increased aggressiveness, and changes in interpersonal relationships. Fatal crash rates for teens are high largely because of their immaturity combined with driving inexperience. Accident prevention measures, a defensive driving course, and automobile insurance are not the most important topics. Accident prevention, defensive driving, and insurance will not be effective if substance abuse is not addressed.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:724

OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

10.A female 36-year-old bank executive was recently promoted to vice president. She and her husband have two school-age children. The patient is being seen at the clinic and reports severe abdominal pain with diarrhea. During the assessment, the patient explains to the health care worker that she and her family will be moving to another state because of her promotion. Her children are upset about leaving their friends. The health care worker recognizes that which of the following information is a priority for patient teaching?

a.

Providing growth and development information about the school-age child

b.

Recommending a gastroenterologist

c.

Offering to call a moving company

d.

Discussing how a high level of stress can cause illness

ANS: D

An adult experiencing a high level of stress is at a greater risk for accidents and certain stress-related illnesses such as headaches, depression, gastrointestinal disorders, and infections. Although it is important to give the patient information regarding normal stages of growth and development in school-age children; this is not the cause of the symptoms. Referral to a gastroenterologist would occur after stress management techniques have been tried; or symptoms become worse. Calling a moving company does not address the real problem of stress.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:724

OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment

11.An 85-year-old retired man with arthritis has recently been prescribed a new medication by his health care provider for pain management. The health care provider identifies that the patient is currently taking 13 different medications on a daily basis. The health care provider is concerned about the patients safety in the home. Which of the following is most important to assess?

a.

Marital status

b.

Potential for falls

c.

Skin breakdown

d.

Cultural beliefs

ANS: B

The physiological changes associated with aging (85 years old), effects of multiple medications (13 different medications), psychological factors, and acute or chronic disease (arthritis) increase the older adults risk for falls and other types of accidents. Fear of falling is common among community-dwelling older adults, who both do and do not have a history of falling. As a result of their fear, many older adults avoid activities or change the way in which they walk and position themselves, making them more at risk for falling. It is important to learn what conditions increase a persons fear of falling so that steps can be taken to remove or change any hazards in the home. Marital status and cultural beliefs are not priority assessment issues for home safety. Skin breakdown could occur if the patient was immobile but this is not the priority home safety issue for this patient and there is no data in the question to indicate the patient is immobile.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:724

OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

12.A nursing student is undergoing a community health clinical rotation. One of the patients is a 53-year-old grandmother who has recently assumed custody of her daughters two young children, ages 3 and 5 years old. Regarding the childrens welfare, which of the following is most important for the nursing student to assess on this visit?

a.

The patients financial ability to care for two young children

b.

The patients knowledge of safety precautions for young children

c.

The patients emotional stability

d.

The patients feelings regarding taking on this responsibility

ANS: B

Some patients are unaware of safety precautions, such as keeping medicine, poisonous plants, or other poisons away from children or reading the expiration date on food products. A nursing assessment will identify the patients level of knowledge regarding home safety so that safety problems can be corrected with an individualized care plan. Although the other responses are important, they are not the focus of home safety issues, but financial and emotional aspects of care.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:724

OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

13.A 75-year-old patient in an acute care hospital who underwent surgery for an abdominal aneurysm developed a urinary tract infection 3 days after placement of a Foley catheter. The nurse believes that this is a reportable incident, and which of the following will happen as a result?

a.

Medicare will be denied to the patient.

b.

Medicare will take the hospital to court.

c.

Nothing; it is not a reportable incident.

d.

Medicare will not reimburse the hospital for this infection.

ANS: D

The Centers for Medicare and Medicaid Services (CMS) names select serious reportable events (SREs) as Never Events (adverse events that should never occur in a health care setting) (US Department of Health and Human Services, 2008). The CMS now denies payment to hospitals for any hospital-acquired conditions resulting from or complicated by the occurrence of certain Never Events that were not present on admission. Many of the hospital-acquired conditions are nurse-sensitive indicators, meaning that nursing interventions directly affect their development. Medicare is not denied to the patient and this is a reportable incident. Medicare does not take hospitals to court; it just denies payment for the Never Event.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:719 | 721

OBJ: Explain the concept of Never Events and a nurses role in prevention.

TOP:Nursing Process: Evaluation

MSC: Client Needs: Safe and Effective Care Environment

14.The nurse is concerned because a 77-year-old patient is weak after abdominal surgery. Which of the following should be done to ensure that one of the preventable conditions identified by the Centers for Medicare and Medicaid does not occur?

a.

Use the rights of medication administration.

b.

Provide frequent opportunities to use the bathroom.

c.

Document thoroughly.

d.

Complete discharge teaching as quickly as possible.

ANS: B

Providing frequent opportunities to use the bathroom helps prevent pressure ulcers, falls, trauma, and even may help prevent an infection from the insertion of a catheterall are listed on the preventable conditions. The Centers for Medicare and Medicaid Services (CMS) names select serious reportable events (SREs) as Never Events (adverse events that should never occur in a health care setting) (US Department of Health and Human Services, 2008). The CMS now denies payment to hospitals for any hospital-acquired conditions resulting from or complicated by the occurrence of certain Never Events that were not present on admission. Many of the hospital-acquired conditions are nurse-sensitive indicators, meaning that nursing interventions directly affect their development. Whereas the rights of medication administration demonstrates safety it does not relate to the preventable conditions identified by CMS, but does relate to the National Patient Safety Goals. Thorough documentation is a legal issue, not a CMS preventable condition. Discharge teaching is not listed on the preventable list and it should not be done quickly.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:719 | 721

OBJ: Explain the concept of Never Events and a nurses role in prevention.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

15.A 5-year-old child was admitted to the pediatric unit of the hospital with the diagnosis of fever of unknown origin. Currently the patients temperature is 105 F. Which of the following is the best way to prevent a patient-inherent accident from occurring?

a.

Keep all electric receptacles covered in the patients room.

b.

Clean up patient spills as they occur.

c.

Pad all bed side rails.

d.

Do not allow the child in the playroom.

ANS: C

One of the more common precipitating factors for a patient-inherent accident is a seizure. Place patients with a seizure disorder on seizure precautions, which are designed to protect patients when seizures occur. Keeping electric receptacles and cleaning up patient spills, and not allowing the child to play in the playroom are all extrinsic factors that are environmentally related and include room clutter, loose electrical cords, and spills.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:725

OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

16.In an outpatient surgery center, the preoperative nurse has the responsibility of starting IVs prior to the patients surgeries. One of the surgeons who works at the center orders a different type of IV fluid than the rest of the surgeons. Which of the following should the nurse be most concerned about in this situation?

a.

Procedure-related accident

b.

Patient-inherent accident

c.

Patient confusion from medications

d.

Potential electrolyte imbalance

ANS: A

Procedure-related accidents are caused by health care providers and include medication and fluid administration errors, improper application of external devices, and improper performance of procedures such as dressing changes. Following an organizations policies and procedures and standards of nursing practice helps prevent procedure-related accidents. Patient-inherent accidents are those in which a patient is the primary reason for the accident. The primary issue is a procedure-related accident because of the surgeons use of a different type of IV, which could cause the nurse to improperly administer the medication; it is not an electrolyte imbalance or confusion. Electrolyte imbalance and confusion from medications are all potential issues that are out of the nurses control.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:725

OBJ: Assess risks to patients safety within health care settings and the home.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

17.The nurse identifies that one of the IV pumps has been malfunctioning and was placed outside a patient room until it could be repaired. To prevent an equipment-related accident from occurring, which action should the nurse take first?

a.

Tag the pump and remove it from the area.

b.

Initiate a work order on the pump.

c.

Clean the pump and put it in the equipment closet.

d.

Call the pump manufacturer.

ANS: A

Initiating the work order on the pump is important, but the first priority is to tag and remove the pump from service. Leaving the pump in the equipment closet could allow the pump to mistakenly be put back into service without be fixed. It is not the nurses job to call the pump manufacturer to report the issues. Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid accidents, do not operate medical equipment without adequate instruction. If you discover a faulty piece of equipment, replace it with the proper working equipment, place a tag on the faulty one, take it out of service and promptly report any malfunctions.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:725

OBJ: Describe nursing interventions specific to the patients age for reducing risk for falls, fires, poisonings, and electrical hazards. TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

18.A patient who underwent surgery for a bowel obstruction yesterday has become confused and has made several attempts to climb out of bed. The nurse is considering options to prevent the patient from harm. Which of the following actions could be delegated to assistive nursing personnel working with the nurse?

a.

Assessing the patient for appropriateness of restraints

b.

Calling the physician for an order for a restraint alternative

c.

Discussing the need for restraints with the patients family

d.

Applying restraints after orders received by the nurse

ANS: D

The skill of applying a restraint can be delegated to trained nursing assistive personnel. However, the nurse is responsible for assessing a patients behavior, determining the need for restraint, the type of restraint to use, and performing patient assessments while restraints are in place. Patients, who are confused, disoriented, or who repeatedly fall or try to remove medical devices (e.g., IV lines or dressings) may require the temporary use of restraints to keep them safe. Restraints are not a solution to a patient problem but rather a temporary means to maintain patient safety. All alternatives must be used before placing patients in restraints. Performing an assessment, obtaining orders from the physician and including the family in the discussion of why restraints are necessary are all jobs that cannot be delegated to a nursing assistive personnel (NAP); and must be performed by the nurse.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:726 | 727 | 738

OBJ:Identify factors to consider in the use of restraints.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

19.A student nurse has been asked by the registered nurse with whom the student nurse is working to apply wrist restraints to a patient who is confused and is trying to remove the endotracheal tube. The student nurse knows that it is important to tie the restraints to which part of the bed?

a.

Side rails

b.

Part of bed frame that moves up and down with the patient

c.

Footboard

d.

Headboard

ANS: B

Attach restraint straps to the portion of the bed frame that moves when raising or lowering the head of the bed. Do not attach to the side rails. Attaching the restraint straps to a portion of the bed frame that does not move (headboard or footboard) will injure the patient.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 740 OBJ: Identify factors to consider in the use of restraints.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

20.A patient is confused and has been restrained to prevent injury. Which of the following is a priority as the nurse plans care for the shift?

a.

Calling the physician for an order for a chemical restraint

b.

Applying the most restrictive restraint to prevent injury

c.

Removing the restraints on the patient at least every 2 hours

d.

Checking on the restrained patient last

ANS: C

Assess proper placement of restraint, skin integrity, pulses, temperature, color, and sensation of the restrained body part. Remove restraints at least every 2 hours or more frequently as determined by agency policy. If patient is violent or noncompliant, remove one restraint at a time and/or have other staff present while removing restraints. Chemical restraints are medications, such as anxiolytics and sedatives, used to manage a patients behavior and are not a standard treatment for a patients condition. Always attempt restraint alternatives before using a restraint. If a restraint is needed, always use the least restrictive device. Checking restrained patients last is not appropriate. Legislation emphasizes reducing the use of restraints. The Joint Commission and Centers for Medicare and Medicaid Services enforce standards for the safe use of restraint devices.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:735 | 736 | 741

OBJ:Identify factors to consider in the use of restraints.

TOP:Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment

21.A nurse working on the medical unit mistakenly administers the wrong medication to a patient. This type of error would be classified as which of the following?

a.

Poisoning accident

b.

Equipment-related accident

c.

Procedure-related accident

d.

Accident related to time management

ANS: C

A procedure-related accident is caused by health care providers and includes medication and fluid administration errors, not putting external devices on correctly, and improperly performing procedures such as dressing changes. A poisoning accident is related to inhaled or ingested substances. An equipment-related accident results from misuse, disrepair, malfunction, or electrical hazard. An accident related to time management deals with the nurses inability to follow an organizations policy and procedures.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:722 | 725

OBJ: Assess risks to patients safety within health care settings and the home.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

22.A confused patient was found wandering in the hallways several times during the shift. What is the most appropriate nursing intervention to prevent a fall by this patient?

a.

Reassigning the patient to a room closer to the nursing station

b.

Using an electronic monitor that sounds an alarm when the patient reaches a near-vertical position

c.

Raising two or four side rails

d.

Placing wrist restraint on the patient during the nighttime hours of sleep

ANS: B

Alarm devices warn nursing staff that a patient is attempting to leave a bed or chair unassisted. There are a variety of types, including a device with a knee band that sounds an alarm when the patient reaches a near-vertical position. An infrared type of alarm is affixed to a headboard or bed frame, allowing a patient to move freely within a bed. If a patient tries to leave the bed, the infrared beam detects motion and sends out an alarm tone. Moving the patient to a room closer to the nursing station does not solve the problem. Raising side rails has the potential to trap parts of the patients body, producing a hazard. The use of side rails alone for a disoriented patient often causes more confusion and further injury. Restraints are not a solution to a patient problem, but a temporary means to patient safety. Restraints are a last resort to prevent injury.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:734

OBJ: Describe nursing interventions specific to the patients age for reducing risk for falls, fires, poisonings, and electrical hazards. TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

23.A toddler is ready to be discharged home after outpatient surgery. When conducting a home safety assessment the childs guardian states, I keep the cleaning supplies under the sink for easy access, and how soon can the child resume swimming in the local pond? Based on this statement, what is the most important safety issue for the nurse to identify?

a.

Standing water in the neighborhood

b.

Reasons for outbursts in behavior

c.

Storage of cleaning supplies in the house

d.

Childs use of safety equipment when riding or skating

ANS: C

Growing, curious children need adults to protect them from injury. Educate young parents or guardians about reducing risks of injuries to children, and teach ways to promote safety in the home. An example is preventing access to poisonous substances like cleaning supplies. Standing water, reasons for outbursts, and use of safety equipment are not issues based upon the guardians response, which focuses on cleaning supplies and swimming.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:722-724

OBJ: Describe nursing interventions specific to a patients age for reducing risk for falls, fires, poisonings, and electrical hazards. TOP: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

24.A pediatric nurse is assessing a patient for a routine physical. The nurse identifies that the parents need additional safety teaching when the parents mentions which of the following?

a.

A 2-year-old child can safely sit in the front seat of a car.

b.

Teenagers need to practice safe sex.

c.

Children need to wear a helmet and safety pads when in-line skating.

d.

Children need to learn to swim even if parents do not have a swimming pool.

ANS: A

A 2-year old cannot sit in the front seat safely, so the nurse needs to correct this misinformation. All children 2 years or older, or those younger than 2 years who have outgrown the rear-facing weight or height limit for their car safety seat (CSS), should use a forward-facing CSS with a harness for as long as possible, up to the highest weight or height allowed by the manufacturer of their CSS. Teenagers practicing safe sex, children wearing a helmet and safety pads when skating, and children learning to swim even if a home pool is not present are all correct and do not need additional teaching.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:722

OBJ: Discuss specific safety risks for patients at each developmental age.

TOP:Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

25.A fire erupts in a hospital waste receptacle in the hallway. What is the nurses first response?

a.

Report the fire.

b.

Attempt to extinguish the fire.

c.

Assist any patients to a safe area.

d.

Close the door to contain the fire.

ANS: C

Use the mnemonic RACE to set priorities in case of fire:

RRescue and remove all patients in immediate danger.

AActivate the alarm. Always do this before trying to extinguish even a minor fire.

CConfine a fire by closing doors and windows and turning off oxygen and electrical equipment.

EExtinguish a fire using an appropriate extinguisher.

Reporting, attempting to extinguish, and closing the door all occur after assisting patients to a safe area.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:737

OBJ: Describe methods to evaluate interventions designed to maintain or promote safety.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

26.A health care provider orders that a confused and disoriented patient be placed in a full hand restraint because of excessive scratching of skin. The nurse acknowledges which of the following?

a.

Restraints are used on an as-needed basis.

b.

No orders or patient consents are needed.

c.

Restraints must be removed every 2 hours to allow for skin assessment, toileting, and nutrition.

d.

An order for restraints may be used indefinitely until the patient no longer needs to be restrained.

ANS: C

Restraints must be removed every 2 hours to allow for skin assessment, toileting, and nutrition. Restraints are only used when other less restrictive measures fail to prevent interruption of therapies. The physicians or health care providers orders are necessary. The need for restraints must be reevaluated every 24 hours.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 734-736 OBJ: Identify factors to consider in the use of restraints.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

27.A patient in the intensive care unit requires mechanical ventilation, a wound VAC system, patient-controlled analgesia, and an intravenous infusion device. Which safety precaution should the nurse implement in the health care setting?

a.

Using two-pronged plugs

b.

Never operating equipment without previous instruction

c.

Using an extension cord to accommodate plugs for all the equipment

d.

Never using equipment without having another nurse assist

ANS: B

To avoid accidents, do not operate medical equipment without adequate instruction. Decrease the incidence of electrical hazards by using a three-pronged grounded plug. Many types of equipment have both electric outlet and battery power sources. Extension cords are a common cause for falls. If an extension cord must be utilized, it should be placed next to the wall to decrease tripping. Using equipment without having another nurse assist is safe behavior.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:725

OBJ: Describe nursing interventions specific to a patients age for reducing risk for falls, fires, poisonings, and electrical hazards. TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

28.A nurse is working in a health facility that creates a culture of safety. Which behavior will the nurse use in this type of facility?

a.

Find blame when problems occur.

b.

Reprimand co-workers when a mistake is made.

c.

Maximize adverse events.

d.

Focus on performance improvement efforts.

ANS: D

These types of organizations foster a patient-centered safety culture by continually focusing on performance improvement efforts, risk-management findings, and safety reports to design a safe work environment. Health care organizations strive to create a culture of safety, one that consistently minimizes, not maximizes, adverse events despite carrying out complex and hazardous work. A culture of safety requires the determination to achieve consistently safe operations and a blame-free environment in which individuals can report errors without fear or reprimand.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 719 OBJ: Describe factors that create a culture of safety.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

MULTIPLE RESPONSE

1.A patient has just undergone an abdominal aortic aneurysm repair. The patient is pulling at the Foley catheter, nasogastric tube, central line, and abdominal dressing and a wrist restraint is applied after an order is received. Later, the patient reports tingling and numbness in the fingers and hand. Which actions should the nurse take? (Select all that apply.)

a.

Remove the restraint immediately.

b.

Remind the patient this will decrease with time.

c.

Notify the health care provider.

d.

Medicate the patient for pain.

e.

Stay with the patient.

ANS: A, C, E

If a patient has altered neurovascular status (tingling and numbness) remove the restraint immediately, stay with the patient, and notify the health care provider. Tingling and numbness will not decrease with time; it will continue to cause damage. The patient does not need pain medication; the restraint is too tight and needs to be removed.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 742 OBJ: Identify factors to consider in the use of restraints.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

2.A group of teenagers are attending a preparation class for babysitters. Which statements by the teenagers indicate a correct understanding of the teaching about safety issues? (Select all that apply.)

a.

Home fires are a major cause of death and injury.

b.

Bacterial food contamination cannot be controlled.

c.

There should be working batteries in the smoke detector.

d.

Temperature changes do not affect the childs safety.

e.

Toddlers are very curious and like to put objects in their mouths.

ANS: A, C, E

The best intervention is to prevent fires. Home fires are a major cause of death and injury. Another problem related to fatal fires is a failure to keep fresh batteries in home smoke detectors. The improper use of cooking equipment and appliances, particularly stoves, is another source for in-home fires. Smoke detectors and carbon monoxide detectors need to be placed strategically throughout a home. Multipurpose fire extinguishers need to be near the kitchen and any workshop areas. Children at these early stages are curious; they explore their environment, and because of an increase in oral activity, put objects in their mouths. If food is prepared and stored properly, food poisoning risk can be decreased. Temperature changes can lead to hypothermia and/or heatstroke or heat exhaustion.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:721 | 723

OBJ: Describe nursing interventions specific to a patients age for reducing risk for falls, fires, poisonings, and electrical hazards. TOP: Nursing Process: Evaluation

MSC: Client Needs: Safe and Effective Care Environment

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