Chapter 27

Question 1

The nurse’s first action after discovering an electrical fire in a patient’s room is to:

1 Activate the fire alarm.

2 Confine the fire by closing all doors and windows.

3 Remove all patients in immediate danger.

4 Extinguish the fire by using the nearest fire extinguisher.

Answer 1

Remove all patients in immediate danger. RACE –remove, activate,contain, extinguish

Question 2

A parent calls the pediatrician’s office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent?

1 Give the child milk.

2 Give the child syrup of ipecac.

3 Call the poison control center.

4 Take the child to the emergency department

Answer 2

Call the poison control center.

Question 3

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient’s data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?

1 Activity intolerance

2 Impaired bed mobility

3 Acute pain

4 Risk for falls

Answer 3

Risk of falls

Question 4

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent?

1 Home accidents

2 Physiological changes of aging

3 Poisoning and child abduction

4 Automobile accidents, suicide, and substance abuse

Answer 4

Automobile accidents, suicide, and substance abuse

Question 5

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.)

1 Insert a urinary catheter.

2 Leave a night light on in the bathroom.

3 Ask the physician to order a restraint.

4 Keep the bed in low position with upper and lower side rails up.

5 Assign a staff member to stay with the patient.

6 Provide scheduled toileting during the night shift.
7 Keep the pathway from the bed to the bathroom clear.

Answer 5

2. Leave a night light on in the bathroom,
3. provide scheduled toileting during the night shift,
4. keep the pathway from the bed to the bathroom clear.

Question 6

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.)

1 Contact the nursing supervisor.

2 Restrict the family’s visiting privileges.

3 Ask the family to stay with the patient if possible.

4 Inform the family of the risks associated with side-rail use.

5 Thank the family for being conscientious and put the four rails up.

6 Discuss alternatives with the family that are appropriate for this patient.

Answer 6

3. Ask the family to stay with the patient if possible
4. Inform the family of the risks associated with side-rail use.
5. Discuss alternatives with the family that are appropriate for this patient.

Question 7

A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order.

___ 1 Explain what you plan to do.

___ 2 Wrap a limb restraint around wrist or ankle with soft part toward skin and secure.

___ 3 Determine that restraint alternatives fail to ensure patient’s safety.

___ 4 Identify the patient using proper identifier.

___ 5 Pad the patient’s wrist.

Answer 7

3. Determine the restraint alternatives fail to ensure patients safety.
4. Identify the patient using proper identifier
5. Explain what you plan to do.
6. Pad the patient’s wrist.
7. Wrap a limb restraint around wrist or ankle with soft part toward skin and secure

Question 8

A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation?

1 Begin cardiopulmonary respiration.

2 Restrain the child to prevent injury.

3 Place a tongue blade over the tongue to prevent aspiration.

4 Clear the area around the child to protect the child from injury.

Answer 8

Clear the area around the child to protect the child from injury.

Question 9

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that:

1 A safe environment promotes patient activity.

2 Assessment focuses on environmental factors only.

3 Teaching home safety is difficult to do in the hospital setting.

4 Most accidents in the older adult are caused by lifestyle factors.

Answer 9

a safe environment promotes patient activity

Question 10

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to:

1 Place a bed alarm device on the bed.

2 Place the patient in a belt restraint.

3 Provide one-on-one observation of the patient.

4 Apply wrist restraints.

Answer 10

Place a bed alarm device on the bed.

Question 11

To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply.)

1 Smoking is prohibited around oxygen.

2 Demonstrate how to adjust the oxygen flow rate based on patient symptoms.

3 Do not use electrical equipment around oxygen.

4 Special precautions may be required when traveling with oxygen

Answer 11

1. Smoking is prohibited around oxygen
2. Do not use electrical equipment around oxygen
3. Special precautions may be required when traveling with oxygen.

Question 12

How does the nurse support a culture of safety? (Select all that apply.)

1 Completing incident reports when appropriate

2 Completing incident reports for a near miss

3 Communicating product concerns to an immediate supervisor

4 Identifying the person responsible for an incident

Answer 12

1. Completing incident reports when appropriate
2. Completing incident reports for a near miss
3. Communicating product concerns to an immediate supervisor

Question 13

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.)

1 Smokes a pack a day

2 Used a cane to walk at home

3 Takes antihypertensive and diuretics

4 History of recent fall

5 Neglect, spatial and perceptual abilities, impulsive

6 Requires assistance with activity, unsteady gait

7 IV line, urinary catheter

Answer 13

3. Takes antihypertensive and diuretics
4. History of recent fall
5. Neglect, spatial and perceptual abilities, impulsive
6. Requires assistance with activity, unsteady gait
7. IV line, urinary catheter

Question 14

At 3 AM the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first?

1 Prepare for an influx of patients

2 Contract the American Red Cross

3 Determine how to restore essential services

4 Evacuate patients per the disaster plan

Answer 14

Prepare for an influx of patientsUse

Question 15

Identify the 6 Joint Commission 2011 National Patient Safety Goals for Hospitals

Answer 15

1. Identify patients correctly (using two identifiers.)
2. Improve staff communication (timely reporting of test results.)
3. Use medicines safely (labeling)
4. Reduce the risk of HAI (hand washing and safe practices)
5. Check patient medicines
   6.Identify Patient safety
   7.

Question 16

Besides being knowledgeable about the environment, nurses must be familiar with what 4 things?

Answer 16

1. Patient’s developmental level
2. Mobility, sensory, and cognitive status
3. Lifestyle Choices
4. Knowledge of common safety precautions

Question 17

Identify the individual risk factors that can pose a threat to safety (4)

Answer 17

1. lifestyle
   2 impaired mobility
2. sensory or communication impairment
3. Lack of sensory awareness

Question 18

List the four major risks to patient safety in the health care environment.

Answer 18

1. Falls
2. Patient-inherent accidents (seizures, burns, inflicted cuts)
3. Procedure-related accidents (med admin, improper procedures)
4. Equipment-related accidents (rapid Iv infusions, Electrical hazards)

Question 19

Identify the specific patient assessments to perform when considering possible threats to the patient’s safety (5)

Answer 19

1. nursing history
2. Patient’s home environment
3. Health Care environment
4. Risk for falls
5. Risk for medial errors

Question 20

Identify the features that should alert nurses to the possibility of a bioterrorism-related outbreak. (5)

Answer 20

1. A disease (or strain) not endemic
2. Unusual antibiotic resistance patterns
3. atypical clinical presentation
4. Clusters of patients arriving from a single locale
5. Other inconsistent elements ( number of cases, mortality and morbidity rates)

Question 21

Identify actual and potential nursing dx that apply to patients whose safety is threatened. (9)

Answer 21

1. Risk for falls
2. Impaired home maintenance
3. Risk for injury
4. Deficient knowledge
5. Risk for poisoning
6. Risk for contamination
7. Risk for suffocation
8. Risk for Thermal injury
9. Risk for trauma

Question 22

Identify the plan for a patient who has a “high risk for falls” (3)

Answer 22

1. Select nursing interventions to promote safety according to patient’s developmental and health care needs
2. Consult with OT and PT for assistive devices
3. Select interventions that will improve the safety of the patient’s home environment

Question 23

Identify the strategies needed to provide safe nursing care. (3)

Answer 23

1. Demonstrate effective use of technology and standardized practices that support safety and quality
2. Demonstrate effective use of strategies to reduce the risk of harm to self and others
3. use appropriate strategies to reduce reliance on memory

Question 24

A physical restraint is___

Answer 24

a human, mechanical, or physical device that is used with or without the patients permission to restrict his or her freedom of movement or normal access to a persons body and is not a usual part of the treatment

Question 25

Use of restraints must meet the following objectives (4)

Answer 25

1. reduce the risk of patient injury from falls 2. prevent interruption of therapy 3. prevent a confused or combative patient from removing life support equipment 4. Reduce the risk of injury to others by the patient

Question 26

Explain why an ambularm is used

Answer 26

to alert the staff when a patient is up and out of bed

Question 27

Explain the mnemonic RACE to set priorities in case of fire

Answer 27

R. Rescue- and remove all patients in immediate danger A. Activate the alarm C. Confine the fire by closing doors and windows and turning off oxygen and electrical equipment E. Extinguish the fire using an extinguisher

Question 28

Explain seizure precautions

Answer 28

are nursing interventions to protect patients from traumatic injury, positioning for adequate ventilation and drainage or oral secretions, and providing privacy and support after the event.

Question 29

Identify the measures with which the nurse must be familiar to reduce exposure to radiation

Answer 29

Limits the time spent near the source, makes the distance from the source as great as possible, and uses shielding devices.

Question 30

The Joint Commission (2011) requires that hospitals have an emergency management plan that addresses: (3)

Answer 30

1. The identification of possible emergency situations and their probable impact 2. The maintenance of adequate an amount of supplies 3. The formal response plan for staff and hospital operations

Question 31

Which of the following would most immediately threaten an individual's safety? 1. 70% humidity 2. A sprained ankle 3. Lack of water 4. Unrefrigerated fresh vegetables Give rationale

Answer 31

an individual's safety is most threatened when physiological needs are not met, including the need for water, oxygen, basic nutrition, and optimum temperature

Question 32

The developmental stage that carries the highest risk of an injury from a fall is: 1. Preschool 2. Adulthood 3. School Age 4. Older Adulthood Give Rationale

Answer 32

Older adulthood is the developmental stage that carries the highest risk of an injury from a fall because of the physiological changes that occur during the aging process, which increase the patient's risk for falls

Question 33

Mrs. Field falls asleep while smoking in bed and drops the burning cigarette on her blanket. When she awakens, her bed is on fire, and she quickly calls the nurse. On observing the fire, the nurse should immediately: 1. Report the fire 2. Attempt to extinguish the fire 3. Assist Mrs. Field to a safe place 4. Close all windows and doors to contain the fire. Give rationale

Answer 33

The nurse should use RACE to set priorities in case of fire. Rescue and remove all patients in immediate danger first

Question 34

Sixteen-year-old Jimmy is admitted to an adolescent unit with a diagnosis of substance abuse. The nurse examines Jimmy and fins that he has bloodshot eyes, slurred speech, and an unstable gait. He smells of alcohol and is unable to answer questions appropriately. The appropriate nursing diagnosis would be: 1. Self-Care Deficit related to alcohol abuse 2. Deficient Knowledge related to alcohol abuse 3. Disturbed Thought Processes related to sensor overload. 4. High Risk for Injury related to impaired sensory perception. Give rationale

Answer 34

The related factors becomes the basis for the selection of nursing therapies

Question 35

The nurse's first action after discovering an electrical fire in a patient's room is to: A. Activate the fire alarm. B. Confine the fire by closing all doors and windows. C. Remove all patients in immediate danger. D. Extinguish the fire by using the nearest fire extinguisher.

Answer 35

Follow the acronym RACE. The first step, R, is to rescue and remove all patients in immediate danger.

Question 36

A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? A. Give the child milk. B. Give the child syrup of ipecac. C. Call the poison control center. D. Take the child to the emergency department.

Answer 36

A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning.

Question 37

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? A. Activity intolerance B. Impaired bed mobility C. Acute pain D. Risk for falls

Answer 37

For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls.

Question 38

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? A. Home accidents B. Physiological changes of aging C. Poisoning and child abduction D. Automobile accidents, suicide, and substance abuse

Answer 38

Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs.

Question 39

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.) A. Insert a urinary catheter. B. Leave a night light on in the bathroom. C. Ask the physician to order a restraint. D. Keep the bed in low position with upper and lower side rails up. E. Assign a staff member to stay with the patient. F. Provide scheduled toileting during the night shift. G. Keep the pathway from the bed to the bathroom clear.

Answer 39

B. Leave a night light on in the bathroom F. Provide scheduled toileting during the night shift G. Keep the pathway from the bed to the bathroom clear Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury.

Question 40

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? A. Activity intolerance B. Impaired bed mobility C. Acute pain D. Risk for falls

Answer 40

For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls.

Question 41

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? A. Home accidents B. Physiological changes of aging C. Poisoning and child abduction D. Automobile accidents, suicide, and substance abuse

Answer 41

Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs.

Question 42

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.) A. Insert a urinary catheter. B. Leave a night light on in the bathroom. C. Ask the physician to order a restraint. D. Keep the bed in low position with upper and lower side rails up. E. Assign a staff member to stay with the patient. F. Provide scheduled toileting during the night shift. G. Keep the pathway from the bed to the bathroom clear.

Answer 42

B. Leave a night light on in the bathroom F. Provide scheduled toileting during the night shift G. Keep the pathway from the bed to the bathroom clear Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury.

Question 43

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? A. Activity intolerance B. Impaired bed mobility C. Acute pain D. Risk for falls

Answer 43

For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls.

Question 44

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? A. Home accidents B. Physiological changes of aging C. Poisoning and child abduction D. Automobile accidents, suicide, and substance abuse

Answer 44

Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs.

Question 45

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.) A. Insert a urinary catheter. B. Leave a night light on in the bathroom. C. Ask the physician to order a restraint. D. Keep the bed in low position with upper and lower side rails up. E. Assign a staff member to stay with the patient. F. Provide scheduled toileting during the night shift. G. Keep the pathway from the bed to the bathroom clear.

Answer 45

B. Leave a night light on in the bathroom F. Provide scheduled toileting during the night shift G. Keep the pathway from the bed to the bathroom clear Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury.

Question 46

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) A. Contact the nursing supervisor. B. Restrict the family's visiting privileges. C. Ask the family to stay with the patient. D. Inform the family of the risks associated with side-rail use. E. Thank the family for being conscientious and put the four rails up. F. Discuss alternatives with the family that are appropriate for this patient.

Answer 46

c. ask the family to stay with the patient D. inform the family of the risks associated with side-rail use. F. Discuss alternatives with the family that are appropriate for this patient. The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presences of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided.

Question 47

A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? A. Begin cardiopulmonary respiration. B. Restrain the child to prevent injury. C. Place a tongue blade over the tongue to prevent aspiration. D. Clear the area around the child to protect the child from injury.

Answer 47

D. Clear the area around the child to protect the child from injury. Once a seizure begins, you need to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth. See the Skills in the chapter for more information.

Question 48

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: A. A safe environment promotes patient activity. B. Assessment focuses on environmental factors only. C. Teaching home safety is difficult to do in the hospital setting. D. Most accidents in the older adult are caused by lifestyle factors.

Answer 48

a. a safe environment promotes patient activity Older adults are frequently fearful of falling and thus often limit activity. A safe environment, which decreases the risk of a fall, promotes patient activity.

Question 49

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: A. Place a bed alarm device on the bed. B. Place the patient in a belt restraint. C. Provide one-on-one observation of the patient. D. Apply wrist restraints.

Answer 49

a. place a bed alarm device on the bed Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently.

Question 50

To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply.) A. Smoking is prohibited around oxygen. B. Demonstrate how to adjust the oxygen flow rate based on patient symptoms. C. Do not use electrical equipment around oxygen. D. Special precautions may be required when traveling with oxygen

Answer 50

a. Smoking is prohibited around O2 c. Do not use electrical equipment around oxygen D. Special precautions may be required when traveling with oxygen. When oxygen is in use, precautions need to be taken to prevent fire and protect the patient. Patients need to be taught precautions, which include posting "Oxygen in Use" signage, not using oxygen around electrical equipment or flammable products, properly handling oxygen cylinders/containers, ensuring that tubing is unobstructed, not adjusting liter flow without a physician's order, and taking precautions when traveling with oxygen.

Question 51

How does the nurse support a culture of safety? (Select all that apply.) A. Completing incident reports when appropriate B. Completing incident reports for a near miss C. Communicating product concerns to an immediate supervisor D. Identifying the person responsible for an incident

Answer 51

a. Completing incident reports when appropriate b. Completing incident reports for a near miss c. Communicating product concerns to an immediate supervisor. Completing incident reports for actual and near-miss events helps the facility track information and identify trends and patterns that need to be addressed. Communicating product concerns to a responsible supervisor allows the facility to further investigate and determine if additional action is required.

Question 52

How does the nurse support a culture of safety? (Select all that apply.) A. Completing incident reports when appropriate B. Completing incident reports for a near miss C. Communicating product concerns to an immediate supervisor D. Identifying the person responsible for an incident

Answer 52

a. Completing incident reports when appropriate b. completing incident reports fora near miss c. Communicating product concerns to an immediate supervisor Completing incident reports for actual and near-miss events helps the facility track information and identify trends and patterns that need to be addressed. Communicating product concerns to a responsible supervisor allows the facility to further investigate and determine if additional action is required.

Question 53

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.) A. Smokes a pack a day B. Used a cane to walk at home C. Takes antihypertensive and diuretics D. History of recent fall E. Neglect, spatial and perceptual abilities, impulsive F. Requires assistance with activity, unsteady gait G. IV line, urinary catheter

Answer 53

c. Takes antihypertensive and diuretics D. Hx of recent fall E. Neglect, spatial and perceptual abilities, impulsive F. Requires assistance with activity, unsteady gait g. IV line, urinary catheter Smoking is not a risk factor for falls. Because the patient used the cane at home, it is not a current risk factor for falls. Risk is determined by his current status.

Question 54

At 3 AM the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? A. Prepare for an influx of patients B. Contact the American Red Cross C. Determine how to restore essential services D. Evacuate patients per the disaster plan

Answer 54

Prepare for an influx of patients The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the disaster plan. Patients may need to be evaluated but not initially. The American Red Cross is not contacted initially. Determination of how to restore essential services is part of the disaster plan and is determined before an actual event.

Question 55

Home health nurse is in the home her chief concern for her patient is: (select all that apply) A. basic needs are met B. Reduces transmission of pathogens by hand washing C. Reduces the likelihood of falls D. Taking naps when the patient does

Answer 55

A. Basic needs are met B. Reduces transmission of pathogens by hand washing C. Reduces the likelihood of falls The primary duty for nurses is to protect clients from harm and to keep clients safe.

Question 56

``` As a nurse in the hospital setting, the nurse is made aware of a bomb on the floor. Hospital policy aside, the nurse should use which mnemonic: ( select all that apply) A. SBAR B. APIE C. OLDCART D. RACE ```

Answer 56

SBAR and RACE Situation, background, assessment, and recommendation or Rescue, Alarm, Contain, and Extinguish SBAR in case you find the bomb or the policy and Race if there is a fire.

Question 57

Safety risk in the health care facility include but the following: a. falls b. medical errors c. Chemical use d. Client-inherent accidents e. procedure related accidents f. drowning

Answer 57

all but drowning are safety risks. Drowning is not a concern

Question 58

A patient is confused and disorientated. She keeps getting out of bed and attempting to use the bathroom in the corner thinking it is the bathroom. What is the best course of action for a nurse: a. Put a bedside toilet near the bedside and explain the use b. restraints c. Chemcial restraint d. Light on for illumination, side rails up on one side of the bed, inform family members of the situation.

Answer 58

A. put a beside toilet near the bedside and explain the use D. Light on for illumination, side rails up on one side of the bed and inform the family members of the situation. Restraints are only used if absolutely necessary. They are physician ordered.