Chapter 32 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 32

Question 1

Type: MCSA

Which safety hazard would the nurse take into consideration when planning care for an older client?

1. Burns

2. Drowning

3. Poisoning

4. Suffocation

Correct Answer: 1

Rationale 1: Falls, burns, and pedestrian and motor vehicle crashes are safety hazards in older adults.

Rationale 2: Drowning and poisoning are seen in the toddler age client.

Rationale 3: Drowning and poisoning are seen in the toddler age client.

Rationale 4: Suffocation is a hazard in newborns and infants.

Global Rationale: Page Reference: 727

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 04 Identify common potential hazards throughout the life span.

Question 2

Type: MCSA

What would the nurse identify as a safety hazard in an infant?

1. Alcohol consumption

2. Drowning

3. Pedestrian accidents

4. Suffocation in the crib

Correct Answer: 4

Rationale 1: Exposure to alcohol consumption is a safety hazard to a fetus.

Rationale 2: Drowning is a safety hazard in toddlers and preschoolers.

Rationale 3: Pedestrian accidents are safety hazards in the older adult.

Rationale 4: Suffocation in the crib is a safety hazard for both newborns and infants.

Global Rationale: Page Reference: 716

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Identify common potential hazards throughout the life span.

Question 3

Type: MCSA

What should the nurse instruct a pregnant client is a safety hazard to the developing fetus?

1. Banging into objects

2. Bicycle rides

3. Recreational activities

4. X-rays

Correct Answer: 4

Rationale 1: Banging into objects is what a toddler would be likely to do, not an expectant mother.

Rationale 2: Bicycle rides and recreational activities would be good for the developing fetus; the mother should stay as active as possible during the pregnancy. Physical activity promotes good health.

Rationale 3: Physical activity promotes good health.

Rationale 4: Exposure to x-rays in the first trimester could cause harm to the developing fetus.

Global Rationale: Page Reference: 716

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify common potential hazards throughout the life span.

Question 4

Type: MCSA

How should the nurse use the JCAHO 2006 National Patient Safety Goals to improve communication among caregivers?

1. Review a list of look-alike/sound-alike drugs used in the organization.

2. Use a verification process to confirm the correct procedure.

3. Studying a list of abbreviations that are not to be used throughout the organization.

4. Use the clients room number as an identifier.

Correct Answer: 3

Rationale 1: Annually reviewing a list of look-alike/sound-alike drugs is used to improve the safety of use of medication in an organization-not to improve communication.

Rationale 2: Using a verification process to confirm that the correct procedure for the correct client is to be performed is another way to improve the accuracy of client identification.

Rationale 3: Studying a list of abbreviations, acronyms, and symbols that are not to be used throughout the organization is one of the ways the National Patient Safety Goals improve the communication among caregivers.

Rationale 4: Using the clients room number as an identifier is a passive technique that would improve the accuracy of client identification.

Global Rationale: Page Reference: 720

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Discuss the National Patient Safety Goals.

Question 5

Type: MCSA

Which nursing diagnoses would the nurse use for a client prone to falls?

1. Deficient Knowledge

2. Risk for Injury

3. Risk for Disuse Syndrome

4. Risk for Suffocation

Correct Answer: 2

Rationale 1: Deficient Knowledge deals with injury prevention. A client who is already prone to falls may not have the cognitive ability for a knowledge deficient.

Rationale 2: Risk for Injury is a state in which the individual is at risk as a result of environmental conditions like a fall.

Rationale 3: Risk for Disuse Syndrome is a deterioration of body system as the result of prescribed or unavoidable musculoskeletal inactivity.

Rationale 4: Risk for Suffocation is inadequate air available for inhalation.

Global Rationale: Page Reference: 722

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 05 Give examples of nursing diagnoses, outcomes, and interventions for a client at risk for accidental injury.

Question 6

Type: MCSA

The nursing care goal for a client who is at risk for injury is:

1. Assess the clients mental status.

2. Keep the client dependent on the staff for all care.

3. Make all choices for the client.

4. Remain free from injury.

Correct Answer: 4

Rationale 1: The nurse will need to assess the clients mental status to help accomplish this goal.

Rationale 2: Keeping the client dependent on the staff for care does not encourage independence.

Rationale 3: Making all choices for the client does not encourage independence.

Rationale 4: The major goal for a client who is at risk for injury is for the client to remain injury-free.

Global Rationale: Page Reference: 719

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 05 Give examples of nursing diagnoses, outcomes, and interventions for a client at risk for accidental injury.

Question 7

Type: MCSA

Which intervention will prevent falls in a health care agency?

1. Display the phone number to the nurses station.

2. Keep electrical cords under the bed.

3. Keep the environment tidy.

4. Read label directions.

Correct Answer: 3

Rationale 1: Displaying the phone number to the nurses station is a way to call for help.

Rationale 2: Electrical cords should only be used if necessary, and the maintenance department can help if any of them present a hazard.

Rationale 3: Keeping the environment tidy and free of clutter will go a long way in preventing falls.

Rationale 4: Reading label directions will prevent the wrong use of substances given to the client, but would not directly prevent falls.

Global Rationale: Page Reference: 728

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts:

Learning Outcome: 06 Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism.

Question 8

Type: MCSA

Which intervention would help prevent falls in an older client?

1. Check vision every 5 years.

2. Exercise regularly.

3. Place socks on feet.

4. Turn the light on after getting out of bed.

Correct Answer: 2

Rationale 1: Vision can be a cause of falls, but it should be checked at least once a year; every 5 years is not often enough.

Rationale 2: The client needs to exercise regularly to maintain strength, flexibility, mobility, and balance, which prevents falls.

Rationale 3: Older clients should have something on their feet when walking, but not socks that will allow them to fall. A nonskid-type sock or shoe will help prevent falls.

Rationale 4: The client should be able to turn the light on before getting out of bed as inadequate lighting is another cause for falls.

Global Rationale: Page Reference: 725-726

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism.
07 Explain interventions to prevent falls.

Question 9

Type: MCSA

The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. The nurse advises the mother that she should:

1. Omit the afternoon nap.

2. Place a crib net over the top of the crib.

3. Remove all objects from around the crib.

4. Restrain the child if he gets up more than once.

Correct Answer: 2

Rationale 1: A child of 2 years should still be taking a nap, and that poses a dangerous situation, naptime or bedtime, if the child is still crawling out of the crib.

Rationale 2: A crib net will prevent an active child from climbing out of the crib but will allow him freedom to move about in the crib.

Rationale 3: Just removing objects off the floor from around the crib would not prevent a child from climbing out of a crib.

Rationale 4: Restraining the child would be dangerous and contribute even more to his determination of getting out of the crib.

Global Rationale: Page Reference: 724

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism.
07 Explain interventions to prevent falls.

Question 10

Type: MCSA

What should the nurse do for a client who experiences a seizure?

1. Insert a tongue blade into the clients mouth.

2. Loosen any clothing around the neck and chest.

3. Restrain the client.

4. Turn the client to the supine position if possible.

Correct Answer: 2

Rationale 1: Research has found that more injury can occur to the client if the caregiver tries to place anything in the mouth during the seizure.

Rationale 2: Loosening any clothing around the neck and chest prevents constriction that might occur during the seizure that could compromise the airway.

Rationale 3: A client should never be restrained during a seizure. The nurse should stay with the client and call for assistance, if needed.

Rationale 4: If possible, the client should be turned onto the lateral position, not supine, to allow for any secretions to drain out of the mouth.

Global Rationale: Page Reference: 732

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Discuss implementation of seizure precautions.

Question 11

Type: MCSA

In which situation can the nurse apply restraints to a client?

1. Client wanders around the care area

2. Client is picking at the access site for intravenous infusion of chemotherapy

3. Client needed to use the bathroom and waited for help but didnt want to soil the bed and fell while attempting to walk to the bathroom

4. Client does not want to stay in bed but wants to sit in the lounge with others.

Correct Answer: 2

Rationale 1: Restraints cannot be used for the convenience of the care staff.

Rationale 2: In this situation, the clients actions could hinder his/her health status and a restraint would be indicated.

Rationale 3: This situation would not call for the client to be restrained. The care staff needs to be more attentive to the clients needs.

Rationale 4: This client would not be a candidate for restraints.

Global Rationale: Page Reference: 737

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Discuss the use and legal implications of restraints.

Question 12

Type: MCSA

When applying restraints on a client, the nurse would secure a doctors order and:

1. Assess the restraints every 10 minutes.

2. Pad bony prominences.

3. Secure the restraint to the side rail.

4. Tie the restraint with a square knot.

Correct Answer: 2

Rationale 1: The restraints should be assessed according to agency policy but no less frequent than every 2 hours.

Rationale 2: Padding bony prominences will prevent possible skin breakdown.

Rationale 3: Restraints are never tied to a side rail. The ends should be secured to the part of the bed that moves to elevate the head.

Rationale 4: When a restraint is secured in place, a clove-hitch knot should be used, not a square knot. The clove-hitch knot will not tighten when pulled.

Global Rationale: Page Reference: 732

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts:

Learning Outcome: 12 Verbalize the steps for:
c. Applying restraints.

Question 13

Type: MCSA

An older client diagnosed with Alzheimers disease continually tries to get out of bed at night. Which alternative safety measure would the nurse choose to use with this client?

1. Explain all procedures and treatments.

2. Place a bed safety monitoring device on the bed.

3. Orient the client to surroundings.

4. Use relaxation techniques.

Correct Answer: 2

Rationale 1: Explaining procedures would not be appropriate with this client.

Rationale 2: Alzheimers disease causes impaired intellectual functioning, so a safety device that is weight sensitive would alert the nurse when the client is trying to get out of bed.

Rationale 3: Orienting to surroundings would not be appropriate with this client.

Rationale 4: Using relaxation techniques would not be appropriate with this client.

Global Rationale: Page Reference: 730

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Describe alternatives to restraints.

Question 14

Type: MCSA

Which alternative to a restraint can the nurse use for a client who is confused and wanders?

1. Assign this client to the farthest room from the nurses station.

2. Place a rocking chair in her room.

3. Pull up all the side rails on the bed.

4. Wedge pillows against the side rails on the bed.

Correct Answer: 2

Rationale 1: Assigning the client to the farthest room from the nurses station would be an unsafe move toward the client; closer would be safer than farther.

Rationale 2: Placing a rocking chair in the clients room will help her to expend some of her energy so that she will be less inclined to walk and wander.

Rationale 3: Pulling up all the side rails is a restraint, so that action would not be an alternative.

Rationale 4: Keeping pillows wedged against the side rails will not keep the client from wandering. She is not in the bed.

Global Rationale: Page Reference: 739

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Describe alternatives to restraints.

Question 15

Type: MCSA

Which outcome would the nurse identify as appropriate for an older client to prevent injury?

1. The client will demonstrate an understanding of all limitations.

2. The client will establish a buddy system.

3. The client will make uninformed choices when addressing health issues.

4. The client will take his medication as desired.

Correct Answer: 2

Rationale 1: The client may resent limitations if he is imposed and act out in such a way to cause injury.

Rationale 2: Establishing a buddy system provides social contact, safeguards against abuse, and offers respite for caregivers. It also provides a way for elders to be checked up on daily.

Rationale 3: Making uninformed choices about ones health could be unsafe instead of safe to the client.

Rationale 4: A routine should be established for medication administration with correct dosage to prevent the possibility of overdose toxicity.

Global Rationale: Page Reference: 739

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 04 Identify common potential hazards throughout the life span.
06 Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism.

Question 16

Type: MCSA

What should the nurse instruct a client regarding home safety?

1. Always pull a plug at the plug-in from the wall outlet.

2. Keep plants in the home.

3. Use overloaded outlets when necessary.

4. Remove labels from containers and refill for recycling.

Correct Answer: 1

Rationale 1: Always pull a plug at the plug-in from the wall outlet. Pulling a plug by its cord can damage the cord and plug unit, creating a dangerous situation.

Rationale 2: Not knowing which plants are poisonous and which are not may pose a serious problem for children in the home.

Rationale 3: Always avoid overloading outlets at anytime because this a cause of fire.

Rationale 4: Do not remove container labels or reuse empty containers to store different substances. Laws mandate that the labels of all substances specify an antidote.

Global Rationale: Page Reference: 735

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism.

Question 17

Type: MCSA

Keeping the likelihood of bioterrorism in mind, the nurse would identify which as being the highest concern for homeland security?

1. Cancer

2. Seasonal flu

3. Tuberculosis

4. Smallpox

Correct Answer: 4

Rationale 1: Cancer does not pose a threat to homeland security.

Rationale 2: Seasonal flu does not pose a threat to homeland security.

Rationale 3: Tuberculosis does not pose a threat to homeland security.

Rationale 4: Smallpox, anthrax, botulism, plague, viral hemorrhagic fevers, and tularemia are the agents that are of highest concern with bioterrorism.

Global Rationale: Page Reference: 718

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism.

Question 18

Type: MCSA

While eating in a restaurant, a nurse notices that a customer at the next table begins to clutch his throat while eating a steak. Which of the following responses would the nurse perform first?

1. Ask the customer if he is choking.

2. Attempt to give five back blows.

3. Perform the Heimlich maneuver.

4. Start chest compressions.

Correct Answer: 1

Rationale 1: The first step is to ask if the person is choking.

Rationale 2: Five back blows are reserved for an infant who is choking.

Rationale 3: If he indicates he is, the next step would be to perform the Heimlich maneuver.

Rationale 4: Chest compressions would be given if the person was unconscious; this client is not. He is clutching his throat.

Global Rationale: Page Reference: 735

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism.

Question 19

Type: MCSA

What can the nurse do to promote a safe environment for the client?

1. Keep clutter to a minimum in the clients room.

2. Have the client wear terry cloth slippers.

3. Provide adequate lighting.

4. Turn off alarms to reduce noise.

Correct Answer: 3

Rationale 1: The environment should be clutter-free because any clutter can cause the client to fall.

Rationale 2: Wearing terry cloth slippers would allow the client to fall. The client should have rubber skid-resistant soles.

Rationale 3: Providing adequate lighting will help prevent the client from falling.

Rationale 4: Noise should be kept to a minimum, but turning off alarms would endanger a client.

Global Rationale: Page Reference: 716

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism.

Question 20

Type: MCMA

The nurse is determining a clients risk for injury. What will the nurse assess in this client?

Standard Text: Select all that apply.

1. Age.

2. Mobility.

3. Hearing.

4. Vision.

5. Dietary intake.

Correct Answer: 1,2,3,4

Rationale 1: The ability of a person to protect himself from injury is dependent upon age.

Rationale 2: The ability of a person to protect himself from injury is dependent upon mobility.

Rationale 3: The ability of a person to protect himself from injury is dependent upon hearing.

Rationale 4: The ability of a person to protect himself from injury is dependent upon vision.

Rationale 5: The ability of a person to protect himself from injury is not dependent upon dietary intake.

Global Rationale: Page Reference: 719

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Describe methods to assess a clients risk for injury.

Question 21

Type: MCMA

An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait. What should the nurse assess in this client to promote home safety?

Standard Text: Select all that apply.

1. Presence of grab bars in the bathroom.

2. Absence of scatter rugs on the floors.

3. Correct use of cane to ambulate.

4. Ability to stand in place for a minute before ambulating.

5. Alcohol use with prescribed medications.

Correct Answer: 1,2,3

Rationale 1: For home safety, it would be beneficial for the client with difficulty moving from a sitting to standing position to have grab bars in the bathroom.

Rationale 2: For home safety, it would be beneficial for the client with an unsteady gait not to have scatter rugs on the floor.

Rationale 3: For home safety, it would be beneficial for the client with an unsteady gait to be able to use a cane correctly.

Rationale 4: The ability to stand in place for a minute before ambulating would be applicable if the client were demonstrating signs of orthostatic hypotension.

Rationale 5: The use of alcohol with prescribed medications would be beneficial if the client were prescribed sedatives or hypnotics.

Global Rationale: Page Reference: 725

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Explain interventions to prevent falls.

Question 22

Type: MCSA

A client is being transferred from an acute care facility to a long-term care facility. What information should the nurse provide to the long-term care facility about the clients medications?

1. Nothing, since the medications all need to be reordered at the long-term care facility.

2. Have the clients medication prescriptions filled before going to long-term care facility.

3. Instruct the client to tell the nurses at the long-term care facility what medications are prescribed.

4. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

Correct Answer: 4

Rationale 1: The nurse is responsible for communicating the clients medications to the long-term care facility, and documents this communication.

Rationale 2: The clients medications will not be filled prior to going to the long-term care facility.

Rationale 3: It is not the clients responsibility to communicate medications to the nurses at the long-term care facility.

Rationale 4: The nurse should communicate the clients medications to the nurses at the long-term care facility and document that this communication occurred.

Global Rationale: Page Reference: 717

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism.

Question 23

Type: MCSA

A client is prescribed seizure precautions. The nurse places functioning oral suction equipment in the clients room because:

1. Suctioning might be needed to prevent the aspiration of oral secretions.

2. The client has difficulty swallowing liquids.

3. There was a spare oral suction set up, and the nurse did not want to return it to Engineering.

4. It helps when the client is brushing her teeth.

Correct Answer: 1

Rationale 1: When implementing seizure precautions, the nurse should place oral suction equipment in the clients room because suctioning might be needed to prevent aspiration of oral secretions.

Rationale 2: If the client were having difficulty swallowing liquids, oral suction already would be in the clients room.

Rationale 3: Placing a piece of equipment in a clients room that is not needed is not a good utilization of resources.

Rationale 4: Having oral suction equipment available for teeth brushing is not the best use of the equipment.

Global Rationale: Page Reference: 732

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 08 Discuss implementation of seizure precautions.

Question 24

Type: MCSA

The nurse determines that instruction regarding home safety for a client has been effective when what is assessed?

1. Smoke alarm functioning with new batteries installed.

2. Scatter rugs located in the kitchen and bathroom only.

3. The cord for a space heater stretches across a hallway.

4. Light bulb burned out in the bathroom and living room.

Correct Answer: 1

Rationale 1: The installation and use of a smoke alarm in the home would indicate that home safety instruction has been effective.

Rationale 2: Scatter rugs would indicate that instruction on home safety has not been effective.

Rationale 3: Cords for appliances stretching across major walkways would indicate that instruction on home safety has not been effective.

Rationale 4: Inadequate lighting in major rooms of the home would indicate that instruction on home safety has not been effective.

Global Rationale: Page Reference: 728

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 06 Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, and bioterrorism.

Question 25

Type: MCSA

The nurse is installing a bed safety-monitoring device for a client. What should the nurse do after testing the device and alarm sound?

1. Place the leg band on the client with the leg in a straight horizontal position.

2. Place the sensor under the mattress near the shoulder region.

3. Set a time delay for 30 seconds.

4. Connect the sensor pad to the control unit.

Correct Answer: 1

Rationale 1: After testing the device and alarm sound, the nurse should place the leg band on the client with the leg in a straight horizontal position.

Rationale 2: The sensor should be placed under the mattress at the buttocks area, not the shoulder area.

Rationale 3: Time delays should be between 1 and 12 seconds.

Rationale 4: Connecting the sensor pad to the control unit is the last step when installing the bed safety-monitoring device.

Global Rationale: Page Reference: 730

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12 Verbalize the steps for:
a. Using a bed or chair exit safety monitoring device.

Question 26

Type: SEQ

A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Pad bony prominences on the wrist.

Choice 2. Apply the padded portion of the restraint around the wrist.

Choice 3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight.

Choice 4. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.

Correct Answer: 1,2,3,4

Rationale 1: Prior to applying the wrist restraint, the clients bony prominences should be padded.

Rationale 2: The nurse should apply the padded portion of the restraint around the wrist.

Rationale 3: The nurse should then pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight.

Rationale 4: The nurse should then attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.

Global Rationale: Page Reference: 737

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12 Verbalize the steps for:
c. Applying restraints.

Question 27

Type: MCSA

Of the following activities and skills, what can the nurse safely delegate to the unlicensed assistive personnel?

1. Provide oral fluids to a newly extubated client.

2. Irrigate the indwelling urinary catheter of a client recovering from prostate surgery.

3. Apply a wrist restraint to a client.

4. Administer oral pain medication to a client before attending physical therapy.

Correct Answer: 3

Rationale 1: Providing oral fluid to a newly extubated client should be done first by the nurse, so the client can be assessed for ability to safely swallow.

Rationale 2: Irrigating an indwelling urinary catheter is beyond the scope for UAP.

Rationale 3: Application of ordered restraints and their temporary removal for skin monitoring and care may be delegated to UAP who have been trained in their use.

Rationale 4: Administering medication is beyond the scope for UAP.

Global Rationale: Page Reference: 741

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13 Recognize when it is appropriate to delegate using a bed or chair exit safety monitoring device, implementing seizure precautions, and applying restraints of clients to unlicensed assistive personnel.

Question 28

Type: MCSA

A client is prescribed seizure precautions. What can the nurse delegate to UAP to complete when implementing the precautions?

1. Placing a tongue blade at the head of the bed.

2. Padding the clients bed.

3. Installing oxygen.

4. Checking the oral suction apparatus.

Correct Answer: 2

Rationale 1: Tongue blades are not used as part of seizure precautions, and should not be placed at the head of the bed.

Rationale 2: The nurse can safely delegate the padding of the bed to UAP.

Rationale 3: The nurse should install the oxygen.

Rationale 4: The nurse should check the oral suction apparatus.

Global Rationale: Page Reference: 732

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12 Verbalize the steps for:
b. Implementing seizure precautions.
13 Recognize when it is appropriate to delegate using a bed or chair exit safety monitoring device, implementing seizure precautions, and applying restraints of clients to unlicensed assistive personnel.

Question 29

Type: MCSA

After ambulating a client to the bathroom, the unlicensed assistive personnel did not reattach the clients bed safety-monitoring device, and the client fell out of bed. What should the nurse document?

1. Client fell out of bed; bed safety-monitoring device malfunctioning..

2. Client fell out of bed; client removed leg band of bed safety monitoring device.

3. Client fell out of bed; no observable injuries.

4. Client fell out of bed; bed safety-monitoring device not activated.

Correct Answer: 4

Rationale 1: The bed safety device was not activated. It was not malfunctioning.

Rationale 2: The client did not remove the leg band of the monitoring device.

Rationale 3: The nurse needs to report the fall to the primary care physician.

Rationale 4: The nurse needs to document what occurred with the client and why.

Global Rationale: Page Reference: 731

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14 Demonstrate appropriate documentation and reporting of using a bed or chair exit safety monitoring device, seizure precautions, and applying restraints.

Question 30

Type: MCMA

A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this clients documentation?

Standard Text: Select all that apply.

1. Who assisted the client back to bed.

2. Location of the seizure.

3. Duration of the seizure.

4. Status of airway and use of oxygen.

5. Who discovered the client.

Correct Answer: 2,3,4

Rationale 1: It is not important for the nurse to name the individuals who assisted the client back to bed.

Rationale 2: Documentation should include where the client was when the seizure occurred.

Rationale 3: Documentation should include the duration of the seizure.

Rationale 4: Documentation should include the status of the clients airway and use of oxygen.

Rationale 5: It is not important for the nurse to name the individual who found the client having a seizure.

Global Rationale: Page Reference: 733

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Discuss implementation of seizure precautions.

Question 31

Type: MCMA

Which method will the nurse use to assess a clients risk for injury?

Standard Text: Select all that apply.

1. Cognitive awareness.

2. Mobility.

3. Nursing history.

4. Physical examination.

5. Health status.

Correct Answer: 3,4

Rationale 1: Cognitive awareness, mobility, and health status are factors affecting safety.

Rationale 2: Cognitive awareness, mobility, and health status are factors affecting safety.

Rationale 3: A nursing history and physical examination are methods to assess a client at risk for injury.

Rationale 4: A nursing history and physical examination are methods to assess a client at risk for injury.

Rationale 5: Cognitive awareness, mobility, and health status are factors affecting safety.

Global Rationale: Page Reference: 719

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Plan strategies to maintain safety in the health care setting, home, and community, including prevention strategies across the life span for thermal injury, fires, falls, seizures, poisoning, suffocation or choking, excessive noise, electric hazards, firearms, radiation, and bioterrorism.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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