Deck 1 Chapter 27 - Patient Safety and Quality

Question 1

A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?

a. “Every December is the time to change batteries on the carbon monoxide detector.”
b. “I will schedule an appointment with a chimney inspector next week.”
c. “If I feel dizzy when using the heater, I need to have it inspected.”
d. “When it is cold outside in the winter, I will use a non-vented furnace.”

Answer 1

d. “When it is cold outside in the winter, I will use a non-vented furnace.”

Rationale: Using a nonvented heater introduces carbon monoxide into the environment and decreases the available oxygen for human consumption and the nurse should follow up to correct this behavior. Checking the chimney and heater, changing the batteries on the detector, and following up on symptoms such as dizziness, nausea, and fatigue are all statements that are safe and appropriate and need no follow-up.

Question 2

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient’s health care needs?

a. The electricity was turned off 3 days ago.
b. The water comes from the county water supply.
c. A son and family recently moved into the home.
d. This home is not furnished with a microwave oven.

Answer 2

a. The electricity was turned off 3 days ago.

Rationale: Electricity is needed for refrigeration of food, and lack of electricity could have contributed to the nausea, vomiting, and diarrhea due to food poisoning. This discussion about the patient’s electrical needs can be referred to social services. Foods that are inadequately prepared or stored or subject to unsanitary conditions increase the patient’s risk for infections and food poisoning, and an assessment should include storage practices. The water supply, the increased number of individuals in the home, and not having a microwave may or may not be concerns but do not pertain to the current health care needs of this patient.

Question 3

The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?

a. 60° to 64° F
b. 65° to 75° F
c. 15° to 17° C
d. 25° to 28° C

Answer 3

b. 65° to 75° F

Rationale: A person’s comfort zone is usually between 18.3° and 23.9° C (65° and 75° F). The other ranges are too low or too high and do not reflect the average person’s comfort zone.

Question 4

A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?

a. Respiratory rate
b. Temperature
c. Apical pulse
d. Blood pressure

Answer 4

b. Temperature

Rationale: The temperature indicates the patient is experiencing hypothermia. Homeless individuals are more at risk for hypothermia. While all the vital signs are low, the most critical vital sign at this time is the temperature.

Question 5

A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?

a. Wash hands
b. Wash wound
c. Wear gloves
d. Wear eye protection

Answer 5

a. Wash hands

Rationale: One of the most effective methods for limiting the transmission of pathogens is the medically aseptic practice of hand hygiene. The most common means of transmission of pathogens is by the hands. While washing the wound is needed, the best method to prevent transmission is hand hygiene. Wearing gloves and possibly eye protection help protect the nurse, but handwashing is best for limiting the transmission of pathogens.

Question 6

The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event?

a. No blood incompatibility occurs with a blood transfusion.
b. A surgical sponge is left in the patient’s incision.
c. Pulmonary embolism after lung surgery
d. Stage II pressure ulcer

Answer 6

b. A surgical sponge is left in the patient’s incision.

Rationale: The Centers for Medicare and Medicaid Services names select serious reportable events as Never Events (i.e., adverse events that should never occur in a health care setting). A surgical sponge left in a patient’s incision is a Never Event. No blood incompatibility reaction is safe practice. Pulmonary embolism after certain orthopedic procedures is like a total knee and hip replacement. Stage III and IV pressure ulcers are Never Events.

Question 7

The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next?

a. Do nothing, no harm has occurred.
b. Notify the health care provider.
c. Complete an incident report.
d. Assess the patient.

Answer 7

b. Notify the health care provider.

Rationale: Report immediately to physician or health care provider if the patient sustains a fall or an injury. The nurse must provide safe care, and doing nothing is not safe care. The scenario indicates the nurse has already assessed the patient. After the patient has stabilized, completing an incident report would be the last step in the process.

Question 8

When making rounds the nurse observes a purple wristband on a patient’s wrist. How will the nurse interpret this finding?

a. The patient is allergic to certain medications or foods.
b. The patient has do not resuscitate preferences.
c. The patient has a high risk for falls.
d. The patient is at risk for seizures.

Answer 8

b. The patient has do not resuscitate preferences.

Rationale: In 2008 the American Hospital Association issued an advisory recommending that hospitals standardize wristband colors: red for patient allergies, yellow for fall risk, and purple for do not resuscitate preferences. Purple does not indicate seizures.

Question 9

A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?

a. 55 years old
b. 20/20 vision
c. Urinary continence
d. Orthostatic hypotension

Answer 9

d. Orthostatic hypotension

Rationale: Numerous factors increase the risk of falls, including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, lower extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications (e.g., anticonvulsants, hypnotics, sedatives, certain analgesics).

Question 10

The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing?

a. Young infant
b. Toddler
c. Preschooler
d. Adolescent

Answer 10

b. Toddler

Rationale: The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and, because of their increased level of oral activity, put objects in their mouths. Young infant is too young. A preschooler and an adolescent are too old.

Question 11

A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session?

a. Proper fit of a bicycle helmet
b. Proper fit of soccer shin guards
c. Proper fit of swimming goggles
d. Proper fit of baseball sliding shorts

Answer 11

a. Proper fit of a bicycle helmet

Rationale: Head injuries are a major cause of death, with bicycle accidents being one of the major causes of such injuries. Proper fit of the helmet helps to decrease head injuries resulting from these bicycle accidents. Goggles, shin guards, and sliding shorts are important sports safety equipment and should fit properly, but they do not protect from this leading cause of death.

Question 12

The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?

a. Increased aggressiveness and blood spots on clothing may indicate substance abuse.
b. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing.
c. Adolescents need information about the effects of uncoordination on accidents.
d. Adolescents need to be reminded to use seat belts primarily on long trips.

Answer 12

a. Increased aggressiveness and blood spots on clothing may indicate substance abuse.

Rationale: Increased aggressiveness (psychosocial clue) and blood spots on clothing (environmental clue) may indicate substance abuse. School-age children are often uncoordinated. Seat belts should be used all the time. In fact, teens have the lowest rate of seat belt use.

Question 13

The nurse is discussing about threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?

a. “Smoking even at parties is not good for my body.”
b. “Our campus is safe; we leave our dorms unlocked all the time.”
c. “As long as I have only two drinks, I can still be the designated driver.”
d. “I am young, so I can work nights and go to school with 2 hours’ sleep.”

Answer 13

a. “Smoking even at parties is not good for my body.”

Rationale: Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and cardiovascular disease. It is prudent to secure belongings. When an individual has been determined to be the designated driver, that individual does not consume alcohol, beer, or wine. Sleep is important no matter the age of the individual and is important for rest and integration of learning.

Question 14

The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?

a. “Are you able to hear the tornado sirens in your area?”
b. “Are you able to read your favorite book?”
c. “Are you able to taste spices like before?”
d. “Are you able to open a jar of pickles?”

Answer 14

a. “Are you able to hear the tornado sirens in your area?”

Rationale: The ability to hear safety alerts and seek shelter is imperative to life safety. Decreased hearing acuity alters the ability to hear emergency vehicle sirens. Natural disasters such as floods, tsunamis, hurricanes, tornadoes, and wildfires are major causes of death and injury. Although age-related changes may cause a decrease in sight that affects reading, and although tasting is impaired and opening jars as arthritis sets in are important to patients and to those caring for them, being able to hear safety alerts is the most important.

Question 15

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint?

a. The patient refuses to call for help to go to the bathroom.
b. The patient continues to remove the nasogastric tube.
c. The patient gets confused regarding the time at night.
d. The patient does not sleep and continues to ask for items.

Answer 15

b. The patient continues to remove the nasogastric tube.

Rationale: Patients who are confused, disoriented, and wander or repeatedly fall or try to remove medical devices (e.g., oxygen equipment, IV lines, or dressings) often require the temporary use of restraints to keep them safe. Restraints can be used to prevent interruption of therapy such as traction, IV infusions, NG tube feeding, or Foley catheterization. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.

Question 16

The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working?

a. The patient continues to get up from the chair at the nurses’ station.
b. The patient gets restless when the sitter leaves for lunch.
c. The patient folds three washcloths over and over.
d. The patient apologizes for being “such a bother.”

Answer 16

c. The patient folds three washcloths over and over.

Rationale: Restraint alternatives include more frequent observations, social interaction such as involvement of family during visitation, frequent reorientation, regular exercise, and the introduction of familiar and meaningful stimuli (e.g., involve in hobbies such as knitting or crocheting or looking at family photos) within the environment or folding washcloths. Getting up constantly can be cause for concern. Apologizing is not an alternative to restraints. Getting restless when the sitter leaves indicates the alternative is not working.

Question 17

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take?

a. Assess the patient.
b. Gather restraint supplies.
c. Try alternatives to restraint.
d. Call the health care provider for a restraint order.

Answer 17

a. Assess the patient.

Rationale: When a patient becomes suddenly confused, the priority is to assess the patient, to identify the reason for change in behavior, and to try to eliminate the cause. If interventions and alternatives are exhausted, the nurse working with the health care provider may determine the need for restraints.

Question 18

The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring?

a. Tile floors, cold food, scratchy linen, and noisy alarms
b. Dirty floors, hallways blocked, medication room locked, and alarms set
c. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach
d. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

Answer 18

d. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

Rationale: Specific risks to a patient’s safety within the health care environment include falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient-inherent issues in the hospital setting but are more of patient satisfaction, infection control, or fire safety issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not procedure-related accidents. These are patient satisfaction issues and control of supply issues and are examples of actually following a procedure correctly. Noisy alarms, call light within reach, and alarms set are not equipment-related accidents but are examples of following a procedure correctly.

Question 19

Which activity will cause the nurse to monitor for equipment-related accidents?

a. Uses a patient-controlled analgesic pump
b. Uses a computer-based documentation record
c. Uses a measuring device that measures urine
d. Uses a manual medication-dispensing device

Answer 19

a. Uses a patient-controlled analgesic pump

Rationale: Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid rapid infusion of IV fluids, all general-use and patient-controlled analgesic pumps need to have free-flow protection devices. Measuring devices used by the nurse to measure urine, computer documentation, and manual dispensing devices can break or malfunction but are not used directly on a patient and are considered procedure-related accidents.

Question 20

A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?

a. Check on the patient once a shift.
b. Encourage visitors in the early evening.
c. Place all four side rails in the “up” position.
d. Keep the patient on fall risk until discharge.

Answer 20

d. Keep the patient on fall risk until discharge.

Rationale: A fall-reduction program includes a fall risk assessment of every patient, conducted on admission and routinely (see hospital policy) until a patient’s discharge. The timing of visitors would not affect falls. All four side rails are considered a restraint and can contribute to falling. Individuals on high risk for fall alerts should be checked frequently, at least every hour.

Question 21

A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident?

a. Pathogenic asepsis
b. Medical asepsis
c. Surgical asepsis
d. Clean asepsis

Answer 21

c. Surgical asepsis

Rationale: The potential for infection is reduced when surgical asepsis is used for sterile dressing changes or any invasive procedure such as insertion of a urinary catheter. Pathogenic and clean asepsis are not types of asepsis. Medical asepsis is not sterile.

Question 22

A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?

a. Identifies patient with one identifier before transporting to x-ray department
b. Initiates an intravenous (IV) catheter using clean technique on the first try
c. Uses medication bar coding when administering medications
d. Obtains vital signs to place on a surgical patient’s chart

Answer 22

c. Uses medication bar coding when administering medications

Rationale: One of the National Patient Safety Goals is to use medicines safely. For example, proper preparation and administration of medications, use of patient and medication bar coding, and “smart” intravenous (IV) pumps reduce medication errors. Identifying patients correctly is a national patient safety goal, and two identifiers are needed, not one. Another goal is to prevent infection; starting an IV should be a sterile technique, not a clean technique. While obtaining vital signs is a component of safe care, it does not meet a national patient safety goal.

Question 23

During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?

a. The patient is oriented.
b. The patient takes a hypnotic.
c. The patient walks 2 miles a day.
d. The patient recently became widowed.

Answer 23

b. The patient takes a hypnotic.

Rationale: Numerous factors increase the risk of falls, including a history of falling and the effects of various medications such as anticonvulsants, hypnotics, sedatives, and certain analgesics. Being oriented will decrease risk for falls while disorientation will increase the risk of falling. Walking has many benefits, including increasing strength, which would be beneficial in decreasing risk. Becoming widowed would increase stress and may affect concentration but is not a great risk.

Question 24

A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?

a. Determining the need for restraints
b. Assessing the patient’s orientation
c. Obtaining an order for a restraint
d. Applying the restraint

Answer 24

d. Applying the restraint

Rationale: The application and routine checking of a restraint can be delegated to nursing assistive personnel. The skill of assessing a patient’s behavior, orientation to the environment, need for restraints, and appropriate use cannot be delegated. A nurse must obtain an order from a health care provider.

Question 25

A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?

a. Remove the restraint.
b. Place a blanket over the feet.
c. Immediately do a complete head-to-toe neurologic assessment.
d. Take the patient’s blood pressure, pulse, temperature, and respiratory rate.

Answer 25

a. Remove the restraint.

Rationale: If the patient has altered neurovascular status of an extremity such as cyanosis, pallor, and coldness of skin or complains of tingling, pain, or numbness, remove the restraint immediately and notify the health care provider. Light blue is cyanosis, indicating the restraints are too tight, not that the patient is cold and needs a blanket. A complete head-to-toe neurological assessment is not needed at this time. The nurse can take vital signs after the restraint is removed.

Question 26

The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?

a. Monitor for specific symptoms.
b. Manage all patients using standard precautions.
c. Transport patients quickly and efficiently through the elevators.
d. Prepare for post-traumatic stress associated with this bioterrorism attack.

Answer 26

b. Manage all patients using standard precautions.

Rationale: Manage all patients with suspected or confirmed bioterrorism-related illnesses using standard precautions. For certain diseases, additional precautions may be necessary. The early signs of a bioterrorism-related illness often include nonspecific symptoms (e.g., nausea, vomiting, diarrhea, skin rash, fever, confusion) that may persist for several days before the onset of more severe disease. Limit the transport and movement of patients to movement that is essential for treatment and care. Psychosocial concerns (post-traumatic stress) are important but are not the first priority at this moment.

Question 27

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?

a. Impaired home maintenance
b. Deficient knowledge
c. Risk for poisoning
d. Risk for injury

Answer 27

d. Risk for injury

Rationale: The patient’s behaviors support the nursing diagnosis of Risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the scenario indicates that this patient lacks knowledge or is at risk for poisoning. Nothing in the scenario refers to the patient’s home maintenance.

Question 28

A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?

a. Risk for injury: Check on patient every 15 minutes.
b. Risk for suffocation: Place “Oxygen in Use” sign on door.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.

Answer 28

a. Risk for injury: Check on patient every 15 minutes.

Rationale: The priority nursing diagnosis is Risk for injury. This patient could cause harm to self by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include more frequent observations. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints. However, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate that the patient has a disturbed body image or that the patient is at risk for suffocation.

Question 29

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient’s application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient’s plan of care?

a. Risk for falls
b. Deficient knowledge
c. Risk for suffocation
d. Impaired physical mobility

Answer 29

b. Deficient knowledge

Rationale: The patient has a knowledge need and requires instruction regarding the device and its purpose and procedure. The nurse will intervene by teaching the patient about the sequential compression device and instructing the patient to call for assistance when getting up to go to the bathroom in the future, so that the nurse may assist with removal and proper reapplication. No data support a risk for falls, impaired physical mobility, or suffocation.

Question 30

The nurse enters the patient’s room and notices a small fire in the headlight above the patient’s bed. In which order will the nurse perform the steps, beginning with the first one?

1. Pull the alarm.
2. Remove the patient.
3. Use the fire extinguisher.
4. Close doors and windows.

a. 2, 1, 4, 3
b. 1, 2, 4, 3
c. 1, 2, 3, 4
d. 2, 1, 3, 4

Answer 30

a. 2, 1, 4, 3

Rationale: Nurses use the mnemonic RACE to set priorities in case of fire. The steps are as follows: Rescue and remove all patients in immediate danger; Activate the alarm; Confine the fire by closing doors and windows; and Extinguish the fire using an appropriate extinguisher.

Question 31

The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?

a. “The number for poison control is 800-222-1222.”
b. “Never induce vomiting if my grandchild drinks bleach.”
c. “I should call 911 if my grandchild loses consciousness.”
d. “If my grandchild eats a plant, I should provide syrup of ipecac.”

Answer 31

d. “If my grandchild eats a plant, I should provide syrup of ipecac.”

Rationale: The administration of ipecac syrup or induction of vomiting is no longer recommended for routine home treatment of poisoning. The nurse must intervene to provide additional teaching. All the rest are correct and do not require follow up. The poison control number is 800-222-1222. After a caustic substance such as bleach has been drunk, do not induce vomiting. This can cause further burning and injury as the substance is eliminated. Loss of consciousness associated with poisoning requires calling 911.

Question 32

A home health nurse is assessing a family’s home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up?

a. Plastic grocery bags are neatly stored under the counter.
b. Electric outlets are covered in all rooms.
c. No bumper pads are in the crib.
d. Crib slats are 5 cm apart.

Answer 32

a. Plastic grocery bags are neatly stored under the counter.

Rationale: Plastic grocery bags increase the risk for suffocation. The nurse will follow up with instructions to remove or keep locked or out of reach. All the rest are correct and do not require follow-up. Electrical outlets should be covered to reduce electrical shock. Bumper pads are not used in the crib to prevent suffocation, strangulation, or entrapment. Crib slats should be less than 6 cm apart.

Question 33

Which patient will the nurse see first?

a. A 56-year-old patient with oxygen with a lighter on the bedside table
b. A 56-year-old patient with oxygen using an electric razor for grooming
c. A 1-month-old infant looking at a shiny, round battery just out of arm’s reach
d. A 1-month-old infant with a pacifier that has no string around the baby’s neck

Answer 33

b. A 56-year-old patient with oxygen using an electric razor for grooming

Rationale: The nurse will see the patient shaving with an electric razor first as this is an actual problem. Do not use oxygen around electrical equipment or flammable products. A lighter on the bedside table and a shiny, round battery are potential problems, not actual. Plus, it would be hard, almost impossible, for a 1 month old to actually grab the battery when it is out of arm’s reach. A baby should use a pacifier without strings.

Question 34

A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session?

a. Run wires under the carpet.
b. Disconnect items before cleaning.
c. Grasp the cord when unplugging items.
d. Use masking tape to secure cords to the floor.

Answer 34

b. Disconnect items before cleaning.

Rationale: A guideline to prevent electrical shock is to disconnect items before cleaning. Do not run wires under carpeting. Grasp the plug, not the cord, when unplugging items. Use electrical tape to secure the cord to the floor, preferably against baseboards.

Question 35

The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action?

a. The patient removes the armband to bathe.
b. The patient wears the red nonslip footwear.
c. The patient insists on taking a “water” pill in the evening.
d. The patient who is allergic to penicillin asks the name of a new medicine.

Answer 35

b. The patient wears the red nonslip footwear.

Rationale: A yellow armband is an alert for high risk of falls. Red nonslip footwear helps to grip the floor and decreases the chance of falling. The communication armband should stay in place and should not be removed, so that all members of the interdisciplinary team have the information about the high risk for falls. A red armband indicates an allergy. Give diuretics (“water” pill) in the morning to decrease risk of falls during the night—when most falls occur.

Question 36

An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient?

a. Positions patient’s buttocks close to the front of wheelchair seat
b. Backs wheelchair into elevator, leading with large rear wheels first
c. Places locked wheelchair on same side of bed as patient’s weaker side
d. Unlocks wheelchair for easy maneuverability when patient is transferring

Answer 36

b. Backs wheelchair into elevator, leading with large rear wheels first

Rationale: A correct action when using a wheelchair is to back wheelchair into an elevator, leading with large rear wheels first. A patient’s buttocks should be well back into the seat. A locked wheelchair should be placed on a patient’s strong or unaffected side. Brakes should be securely locked when a patient is transferring.

Question 37

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.)

a. Smoking in bed helps me relax and fall asleep.
b. We never leave candles burning when we are gone.
c. We use the same space heater my grandparents used.
d. We use the RACE method when using the fire extinguisher.
e. There is a fire extinguisher in the kitchen and garage workshop.

Answer 37

a. Smoking in bed helps me relax and fall asleep.
c. We use the same space heater my grandparents used.
d. We use the RACE method when using the fire extinguisher.

Rationale: Incorrect information will cause the nurse to intervene. Accidental home fires typically result from smoking in bed. Advise families to only purchase newer model space heaters that have all of the current safety features. The PASS method is used for fire extinguishers. All the rest are correct and do not require follow-up. Candles should not be left burning when no one is home. Keep a fire extinguisher in the kitchen, near the furnace, and in the garage.

Question 38

The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.)

a. Water outdoor plants with a nozzle and hose.
b. Walk to the mailbox in the summer.
c. Encourage yearly eye examinations.
d. Use bathtubs without safety strips.
e. Keep pathways clutter free.

Answer 38

b. Walk to the mailbox in the summer.
c. Encourage yearly eye examinations.
e. Keep pathways clutter free.

Rationale: Walking to the mailbox in summer provides exercise when pathways are not icy and slick. Encourage annual vision and hearing examinations. Pathways that are clutter free reduce fall risk. Using a hose to water plants and using tubs without safety strips are all items the patient should avoid to help in the prevention of falls in the home.

Question 39

A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.)

a. Health care provider orders restraints prn (as needed).
b. Health care provider writes the type and location of the restraint.
c. Health care provider renews orders for restraints every 24 hours.
d. Health care provider performs a face-to-face assessment prior to the order.
e. Health care provider specifies the duration and circumstances under which the restraint will be used.

Answer 39

b. Health care provider writes the type and location of the restraint.
d. Health care provider performs a face-to-face assessment prior to the order.
e. Health care provider specifies the duration and circumstances under which the restraint will be used.

Rationale: A physician’s/health care provider’s order is required, based on a face-to-face assessment of the patient. The order must be current, state the type and location of restraint, and specify the duration and circumstances under which it will be used. These orders need to be renewed within a specific time frame according to the policy of the agency. In hospital settings each original restraint order and renewal is limited to 8 hours for adults, 2 hours for ages 9 through 17, and 1 hour for children under age 9. Restraints are not to be ordered prn (as needed).

Question 40

The nurse is performing the “Timed Get Up and Go (TUG)” assessment. Which actions will the nurse take? (Select all that apply.)

a. Ranks a patient as high risk for falls after patients takes 18 seconds to complete
b. Teaches patient to rise from straight back chair using arms for support
c. Instructs the patient to walk 10 feet as quickly and safely as possible
d. Observes for unsteadiness in patient’s gait
e. Begins counting after the instructions
f. Allows the patient a practice trial

Answer 40

c. Instructs the patient to walk 10 feet as quickly and safely as possible
d. Observes for unsteadiness in patient’s gait
f. Allows the patient a practice trial

Rationale: The nurse instructs the patient to walk 10 feet (3 m) as quickly and safely as possible and observes for unsteadiness in the patient’s gait. For accuracy, a patient should have one practice trial that is not included in the score. Patient taking less than 20 seconds to complete TUG is adequate for independent mobility. Score over 30 seconds is dependent and at risk for fall. Counting does not begin after instructions. The patient rises from a straight back chair without using arms for support.

Question 41

The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family? (Select all that apply.)

a. Demonstrate how to restrain the patient in the event of a seizure.
b. Instruct the family to move the patient to a bed during a seizure.
c. Teach the family how to insert a tongue depressor during the seizure.
d. Discuss with the family steps to take if the seizure does not discontinue.
e. Instruct the family to reorient and reassure the patient after consciousness is regained.

Answer 41

d. Discuss with the family steps to take if the seizure does not discontinue.
e. Instruct the family to reorient and reassure the patient after consciousness is regained.

Rationale: Prolonged or repeated seizures indicate status epilepticus, a medical emergency that requires intensive monitoring and treatment. Family should know what to do. Family should reorient and reassure the patient after consciousness is regained. Never force apart a patient’s clenched teeth. Do not place any objects into patient’s mouth such as fingers, medicine, tongue depressor, or airway when teeth are clenched. Do not lift patient from floor to bed while seizure is in progress. Do not restrain patient; hold limbs loosely if they are flailing. Loosen clothing.

Question 42

The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.)

a. Where did you fall?
b. What time did the fall occur?
c. What were you doing when you fell?
d. What types of injuries occurred after the fall?
e. Did you obtain an electronic safety alert device after the fall?
f. What are your medical problems that may have caused the fall?

Answer 42

a. Where did you fall?
b. What time did the fall occur?
c. What were you doing when you fell?
d. What types of injuries occurred after the fall?

Rationale: Assess previous falls; using the acronym SPLATT:
Symptoms at time of fall
Previous fall
Location of fall
Activity at time of fall
Time of fall
Trauma after fall
Medical diagnoses and an alert device are not components of SPLATT.

Question 43

The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.)

a. Close all doors.
b. Note evacuation routes.
c. Note oxygen shut-offs.
d. Move bedridden patients in their bed.
e. Wait until the fire department arrives to act.
f. Use type B fire extinguishers for electrical fires.

Answer 43

a. Close all doors.
b. Note evacuation routes.
c. Note oxygen shut-offs.
d. Move bedridden patients in their bed.

Rationale: Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen shut-offs is important in case evacuation is needed. You will move bedridden patients from the scene of a fire by a stretcher, bed, or wheelchair. The nurse cannot wait until the fire department arrives to act. Type C fire extinguishers are used for electrical fires; type B is used for flammable liquids.

Question 44

The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient’s medical record to provide safe care? (Select all that apply.)

a. One family member has gone to lunch.
b. Patient is placed in bilateral wrist restraints at 0815.
c. Bilateral radial pulses present, 2+, hands warm to touch
d. Straps with quick-release buckle attached to bed side rails
e. Attempts to distract the patient with television are unsuccessful.
f. Released from restraints, active range-of-motion exercises completed

Answer 44

b. Patient is placed in bilateral wrist restraints at 0815.
c. Bilateral radial pulses present, 2+, hands warm to touch
e. Attempts to distract the patient with television are unsuccessful.
f. Released from restraints, active range-of-motion exercises completed

Rationale: Proper documentation, including the behaviors that necessitated the application of restraints, the procedure used in restraining, the condition of the body part restrained (e.g., circulation to hand), and the evaluation of the patient response, is essential. Record nursing interventions, including restraint alternatives tried, in nurses’ notes. Record purpose for restraint, type and location of restraint used, time applied and discontinued, times restraint was released, and routine observations (e.g., skin color, pulses, sensation, vital signs, and behavior) in nurses’ notes and flow sheets. Straps are not attached to side rails. Comments about the activities of one family member are not necessarily required in nursing documentation of restraints.