ch 32 Safety NCLEX – Flashcards
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A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? Report the fire. Extinguish the fire. Protect the clients. Contain the fire.
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Protect the clients. Rationale: In the event of a fire, the nurse's priority responsibility is to rescue or protect the clients under his or her care. The next priorities are to report or alert the fire department, contain or confine, and extinguish the fire. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.
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A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? Automobile crashes Drowning and firearms Falls Suicide and homicide
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Automobile crashes Rationale: When educating a group of young to middle-aged adults on safety, it is important to instruct them on the leading cause of injuries in this group. The leading cause of injuries in this group is related to automobile use. Option 2 is the leading cause for school-age children. Option 3 is the leading cause for older adults, and option 4 relates to adolescents. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.
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An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? Leave the bathroom light on. Withhold the client's diuretic medication. Provide a bedside commode. Keep the side rails up.
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Provide a bedside commode. Rationale: The placement of the bedside commode next to his bed will assist in decreasing the number of steps he is required to ambulate. This will assist in protecting him from injury due to falls. Option 1: Leaving the light on would assist the client in locating the bathroom, but would not reduce the risk of fall when rushing to the bathroom. Option 2: The nurse cannot withhold a client's medication without consulting with the primary care provider. Option 4: If the client has orders to be up with assistance and the side rails are up, he is at risk for falls as well as falling from a greater distance. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.
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A mother and her 3-year-old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child? Risk for Suffocation Risk for Injury Risk for Poisoning Risk for Disuse Syndrome
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Risk for Poisoning Rationale: A home that was built prior to 1978 has lead-based paint. The ingestion of lead-based paint chips places that child at risk for elevated serum lead levels and neurologic deficits. The most appropriate nursing diagnosis for this child is Risk for Poisoning. Option 1: The risk for suffocation is greater in infants and is not related to a home with lead-based paint. Options 2 and 4 are not related to lead-based paint. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Nursing Diagnosis.
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A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure? Restrain the client in bed. Ask a family member to stay with the client. Check the client every 15 minutes. Use a bed exit safety monitoring device
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Use a bed exit safety monitoring device. Rationale: Option 4 is an intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety. Option 1 can increase agitation and confusion and removes the client's independence. Option 2 would help but transfers the responsibility to the family member. Option 3 is inappropriate since the client could fall during the unobserved interval and it is not a realistic answer for the nurse. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation
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A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? Select all that apply. Place a padded tongue depressor at the head of the bed. Pad the bed with blankets. Inform the client about the importance of wearing a medical identification tag. Teach the client about epilepsy. Test oral suction equipment.
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Pad the bed with blankets. Test oral suction equipment. Rationale: Options 2 and 5 are measures needed to keep the client safe in the event of another seizure. Option 1 is incorrect because the current nursing literature states to not put anything in the client's mouth during a seizure. Options 3 and 4 are more relevant after the cause of the seizure is known. Seizures are not all classified as epilepsy. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Planning.
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Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting? Keep all of the side rails up. Review prescribed medications. Complete the "get up and go" test. Place the bed in the lowest position.
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Place the bed in the lowest position. Rationale: Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting out of bed is at an appropriate height. Option 1 can cause a fall with injury because the client may fall from a higher distance when trying to get over the rail. Option 2 is important to do as certain medications can increase the risk of falling. However this is not the best answer because it is N/A to all clients. Option 3 would help the nurse to assess a client's risk for falling but would not prevent injury. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.
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Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply. Hire only competent nurses. Improve the nurse's ability to multitask. Establish a reporting system for "near misses." Communicate effectively. Create a culture of trust.
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Establish a reporting system for "near misses." Communicate effectively. Create a culture of trust. Rationale: Reviewing near misses could identify flaws in the system or practices that placed the client at risk. Communication among staff and with clients will increase the efficiency and create an atmosphere where nurses are willing to discuss errors openly so that the flaws in the system can be corrected. Options 1 and 2 are inappropriate answers. A competent nurse may make medication errors. Also, evidence is needed to support these conclusions. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Planning.
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When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority? Sports contribute to an adolescent's self-esteem. Sunbathing and tanning beds can be dangerous. Guns are the most frequently used weapon for adolescent suicide. A driver's education course is mandatory for safety.
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Guns are the most frequently used weapon for adolescent suicide. Rationale: Suicide and homicide are two leading causes of death among teenagers. Adolescent males commit suicide at a higher rate than adolescent females. Options 1 and 2 are true; however, neither would be as high a priority as preventing suicide. Option 4 is not true. A driver's education course does not ensure safe practice. Cognitive Level: Analysis. Client Need: Safe, Effective Care Environment. Nursing Process: Planning.
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The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply. Document the behavior(s) that require continued use of the restraints. Ensure that the restraints are tied to the side rails. Provide range-of-motion exercises when the restraints are removed. Orient the client. Assess the tightness of the restraints.
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Document the behavior(s) that require continued use of the restraints. Provide range-of-motion exercises when the restraints are removed. Orient the client. Assess the tightness of the restraints. Rationale: Standards require documentation of the necessity for restraints. The implementation of range-of-motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint. Option 2 is inappropriate because it may cause injury if the side rail is lowered without untying the restraint. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.
