Deck 3 Module 13 Mobility Flashcards
A client asks the nurse if the staff members make many mistakes because there are so many posters and signs about safety on the walls. Which response by the nurse is best?
A) “The nurses here are safe. The posters are directed at certain members of the healthcare team who have been making more mistakes than usual.”
B) “You don’t need to worry about posters on the wall. Our primary concern is getting you well.”
C) “We never make mistakes here. We want the public to know that we have client safety goals here.”
D) “There is a potential for errors in all healthcare settings. The posters remind the staff and the clients of the need to work together to prevent them.”
D) “There is a potential for errors in all healthcare settings. The posters remind the staff and the clients of the need to work together to prevent them.”
Rationale: Client safety initiatives address collaborative efforts by staff and clients to promote safety in healthcare settings. These initiatives require collaboration by all members of the team, including clients. Mistakes can occur in all healthcare settings; behaviors, not goals, help to prevent them.
Several nurses are discussing the Joint Commission’s 2016 National Patient Safety Goals during a staff meeting. Which element of performance should the nurses implement to meet the goal of identifying clients correctly?
A) Labeling all medications with the client’s name
B) Consistently using two methods to identify the client
C) Asking the client’s name before conducting assessments
D) Marking the intended surgical site on the client
B) Consistently using two methods to identify the client
Rationale: Two elements of performance that accompany the goal to identify clients correctly include consistently using two methods to identify the client and ensuring that clients receiving blood transfusions are correctly identified prior to transfusion. Labeling medications with the medication information helps prevent medication errors, and marking the intended surgical site on the client helps prevent surgical errors. Asking the client’s name before conducting assessments is not associated with a National Patient Safety Goal.
After completing an assessment, the nurse determines a client is at risk for safety issues. Which data supports the nurse’s conclusion?
A) Lives with adult married daughter and family
B) Occasional dizziness with walking
C) Follows a vegetarian diet
D) Receives an annual ophthalmologic examination
B) Occasional dizziness with walking
Rationale: Risks to safety include factors that can impact falls such as mobility issues or balance. Living with family, eating a vegetarian diet, and having annual eye examinations do not increase the client’s risk for safety issues.
Which practices support promotion of health safety? Select all that apply.
A) Exercise every day B) Avoid driving when sleepy or tired C) Eliminate all foods containing fat D) Wear seat belts E) Only see healthcare providers when sick
A) Exercise every day
B) Avoid driving when sleepy or tired
D) Wear seat belts
Rationale: Health promotion involves many different practices, including staying physically active, following guidelines for motor vehicle safety, eating an appropriate diet, and monitoring personal health status. Eliminating all foods containing fat would eliminate necessary nutrients from the diet, and clients should see a healthcare provider at least annually for a checkup even if not sick.
A hospital has created a culture of safety by providing organizational support for safety initiatives and by training and encouraging healthcare employees in the area of safety. What other step is needed to promote safety for everyone in the healthcare environment?
A) Keep a mindset for quality of safe practice
B) Post signs related to safety on the walls
C) Engage clients in their own safety
D) Be a safety advocate for others
C) Engage clients in their own safety
Rationale: Healthcare facilities should use a three-pronged approach to quality and safety for everyone, including organizational support for keeping safety a priority, encouraging employees to consistently choose to follow health safety rules and standards, and actively engaging clients in every aspect of their care, including safety. Keeping a mindset for quality of safe practice and posting signs related to safety relates to the organizational support for safety. Being a safety advocate for others is related to employees maintaining safety standards.
When a nurse performs or observes nursing practices that are not safe, the nurse has a responsibility to report those actions. This principle ties the concept of safety to what other nursing concept?
A) Accountability
B) Advocacy
C) Assessment
D) Clinical Decision Making
A) Accountability
Rationale: Nurses are accountable for their actions, so all unsafe nursing practices should be reported and addressed. This principle does not reflect advocacy, assessment, or clinical decision making.
The nurse is caring for a client with a self-reported latex allergy. Which strategy can the nurse use to ensure the safety of this client?
A) Wear hypoallergenic gloves
B) Wear gloves with powder
C) Wash hands after taking gloves off
D) Keep beta adrenergic agonists on hand
C) Wash hands after taking gloves off
Rationale: The nurse should wear latex-free gloves that are hypoallergenic and powderless. Not all hypoallergenic gloves are latex-free. Powder from the gloves can absorb the latex and be transferred to clients through touch or through the air. Therefore, it is important to wash hands after removing gloves, especially gloves with powder. Beta adrenergic agonists are used for the treatment of asthma, which may develop with chronic latex exposure in a sensitive individual, but it will not affect the early symptoms of latex allergy.
The nurse is caring for a 230-lb client who needs to be repositioned every 2 hours. While repositioning the client, the nurse injured a muscle in her back. To prevent the injury and ensure safety for both the nurse and client, what should the nurse have done differently in this situation?
A) She should have used proper lifting techniques.
B) She should have repositioned the client only if the client requested it.
C) She should have questioned the physician about the need to reposition the client.
D) She should have asked for help from another nurse.
D) She should have asked for help from another nurse.
Rationale: When moving or repositioning clients, especially larger clients, the nurse should always ask for help from another healthcare worker to prevent injury. Although using proper lifting techniques is important, they do not guarantee that injuries will not occur. In addition, there is no evidence that the nurse was not already using proper lifting techniques. The nurse should question physician orders if she is unclear about the reasoning for the order, but this is a standard best practice and would likely not require questioning. The nurse should reposition the client as ordered, not only when the client requests it.
The nurse is conducting a class for a group of pregnant clients. Which topics should the nurse include when teaching this group about safety of the fetus?
A) Pedestrian accidents
B) Suffocation in the crib
C) Alcohol consumption
D) Drowning
C) Alcohol consumption
Rationale: Alcohol consumption is a safety hazard for the fetus, and pregnant women should be educated about the importance of not drinking alcoholic beverages while pregnant. Suffocation in the crib is a safety hazard for both newborns and infants. Drowning is seen in toddlers and preschoolers, and pedestrian accidents are seen in the older adult.
A nurse conducted a class on fall prevention for a group of older adult clients in the community. Which observation during a client home visit indicates that teaching on fall prevention was effective?
A) All meat is placed in the freezer.
B) The locks were changed on the doors.
C) Scatter rugs are placed in the kitchen.
D) A shower seat was placed in the shower.
D) A shower seat was placed in the shower.
Rationale: A shower seat in the shower can prevent falls. The client who installed the seat has understood the nurse’s teaching. Changing the locks may promote safety if there have been frequent break-ins, but there is no evidence of that. Scatter rugs in any area of the home are a safety hazard. Placing meat in the freezer does not help prevent falls.
The nurse is conducting a home risk assessment for a family with toddler and preschool-age children. Which should the nurse identify as the priority safety hazard?
A) Safety plugs in electrical outlets
B) Medications on the kitchen counter
C) Lack of helmets next to bicycles
D) Child locks on the doors
B) Medications on the kitchen counter
Rationale: The nurse would instruct the parents to keep medications out of the children’s reach. Medication poisoning happens easily with young toddlers and preschool-age children who think the medication is candy. Safety plugs are appropriate for this age group. Child locks are appropriate to keep toddlers from wandering out to the street. A lack of a helmet next to a bike does not mean there are no helmets in the house. This finding would cause the nurse to ask more questions but is not considered a definite safety risk.
The home health nurse is talking with the parents outside the bathroom door while their 1-year-old twins are playing in the tub. Which client statement would require further safety teaching?
A) “Why don’t we talk in the living room?”
B) “Let me get the children out of the tub so we can talk.”
C) “I do not like to leave the children alone in the bathroom.”
D) “I often bathe the children together.”
A) “Why don’t we talk in the living room?”
Rationale: Infants and toddlers are at risk for drowning, even in small amounts of water. The nurse would want to teach the parent that it is never appropriate to leave young children unsupervised in the tub. Taking the children out of the tub and not wanting to leave toddlers alone in the bathroom demonstrates an awareness of risk. There is no risk with bathing the children together.
Reducing the risk of functional decline in older adults can help prevent which complication?
A) Pressure ulcers
B) Macular degeneration
C) Hyperglycemia
D) Hearing loss
A) Pressure ulcers
Rationale: By reducing the risk of functional decline, nurses and independent older adults can help prevent complications such as pressure ulcers, delirium and depression, decreased mobility, loss of independence, and incontinence. Macular degeneration, hearing loss, and hyperglycemia are not complications that occur as a result of functional decline.
The nurse is assessing a 12-year-old male client. The client is within the normal range for height, weight, and body mass index (BMI) for his age. The client plans to play contact sports at school this year. He lives with his mother and attends after-school events when she is working late. What education should the nurse identify as a priority for this client to promote safety?
A) The importance of learning how to feel secure when he is at home alone
B) The importance of maintaining a normal weight and participating in physical activity
C) The importance of using safety equipment when playing contact sports
D) The importance of good hygiene practices and healthy diet
C) The importance of using safety equipment when playing contact sports
Rationale: The client’s biggest safety risk is a risk of injury from contact sports. The nurse should encourage the client to use proper safety equipment to avoid injury. Promoting a sense of security is important for latchkey children, but this client does not appear to be home alone for extended periods based on participation in school, sports, and after-school activities. The client already has a normal weight and participates in physical activity, so education related to these topics is not as important as sports safety. There is no evidence that this client has poor hygiene or an unhealthy diet.
A) Teach the client about ergonomic aids for computer use
B) Teach the client about age-appropriate medical screenings
C) Tell the client to seek medical help for injuries
D) Encourage the client to not drive while distracted
B) Teach the client about age-appropriate medical screenings
Rationale: The nurse can provide education in many areas related to disease prevention, including teaching about age-appropriate medical screenings. Teaching the client about ergonomic aids for computer use, telling the client to seek medical help for injuries, and encouraging the client to not drive while distracted are all methods to prevent injury, not disease.
The nurse is providing care to a 12-year-old child with special needs and his caregiver. What strategies should the nurse help the caregiver teach the child to improve the child’s safety?
A) Teach the child to schedule routine immunizations
B) Teach the child how to use a telephone to call for help
C) Teach the child to maintain airway with suctioning
D) Teach the child to avoid secondhand smoke exposure
B) Teach the child how to use a telephone to call for help
Rationale: For children with special needs, the caregiver can work with the child to teach the child how to use a telephone to call for help when needed. The other actions are typically the responsibility of the caregiver or require the caregiver’s help, including scheduling routine immunizations, keeping the child away from secondhand smoke, and suctioning the airway.
A nurse is assessing the hospital environment in order to decrease the risk for client falls. Which intervention should the nurse implement to decrease the risk of client falls?
A) Encourage the client to wear diapers.
B) Read label directions.
C) Lower side rails on client beds.
D) Clean the environment of clutter.
D) Clean the environment of clutter.
Rationale: Keeping the environment tidy and free of clutter will go a long way in preventing falls. Lowering side rails on client beds would increase the risk of falls. Reading label directions will prevent the wrong use of substances given to the client but would not directly prevent falls. Encouraging the client to wear diapers would increase functional decline, and it is not an appropriate strategy to help reduce falls.
A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After exhausting all alternatives, the nurse applies soft restraints to protect the client’s airway. Which action should the nurse take next?
A) Notify the primary healthcare provider.
B) Notify the family of the need for restraints.
C) Reassess the need for the restraints in 8 hours.
D) Document the application of restraints in the chart.
A) Notify the primary healthcare provider.
Rationale: Restraints can only be applied under the order of a physician. When there is an urgency to protect the client and others, restraints can be applied and then the physician should be notified immediately to write an order for the restraints. The nurse would notify the family if present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the primary healthcare provider. Most agencies require reassessment of need every 1-2 hours.
The nurse is developing a plan of care for a client who is at risk for falls. Which interventions would be appropriate for the nurse to include in the plan of care? Select all that apply.
A) Apply physical restraints if the client gets out of bed.
B) Assess the client’s vision and make sure he is using any prescribed eyewear.
C) Use side rails on client beds.
D) Keep frequently used items within easy reach.
E) Provide slippers for the client to wear while ambulating.
B) Assess the client’s vision and make sure he is using any prescribed eyewear.
C) Use side rails on client beds.
D) Keep frequently used items within easy reach.
Rationale: Assessing the client’s vision and making sure he is using any prescribed eyewear is an appropriate action. Poor and blurry vision increases the client’s risk of falling. Using side rails on the client bed to prevent falls while the client is sleeping is an appropriate intervention. Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to prevent falls. It is not appropriate for the nurse to apply physical restraints if the client gets out of bed. The nurse should ensure that the client wears shoes with adequate traction while ambulating. Slippers may increase the risk for falls.
The staff nurses are discussing interventions to reduce the risk of infection for the client population. Which intervention is the most important to decrease client infection?
A) Practice appropriate hand hygiene.
B) Assess vital signs once daily.
C) Raise the temperature in the client’s room.
D) Wear a mask for all client care.
A) Practice appropriate hand hygiene.
Rationale: Hand hygiene is always the first and best way to stop the spread of microorganisms, which cause infections. Assessing vital signs is important but should be done more frequently than once daily. Raising the temperature in a client’s room would contribute to the growth of microorganisms. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.
While reviewing safety precautions with the staff in a long-term care facility, which step should the nurse emphasize that helps to promote a safe environment for the clients?
A) Keep clutter out of the hallway and inside the client’s room.
B) Provide dim lighting.
C) Turn off alarms to reduce noise.
D) Have the client wear shoes with rubber skid-resistant soles.
D) Have the client wear shoes with rubber skid-resistant soles.
Rationale: Having the client wear shoes with rubber skid-resistant soles is the most appropriate intervention to decrease the risk of client falls, which will promote a safe environment. Dim lighting will increase the risk of client falls. Both the hallways and the clients’ rooms should be clutter free. Noise should be kept to a minimum, but turning off alarms would endanger clients.
A novice nurse has accepted a position on a medical-surgical unit at a local university hospital. In order to provide safe care to clients, the nurse should plan to develop which competency?
A) Creating a culture of trust within the hospital
B) Functioning as a member of the healthcare team
C) Promoting appropriate values that clients should adopt
D) Reporting families for bringing food to the client’s room
B) Functioning as a member of the healthcare team
Rationale: New nurses should learn about the healthcare team members and determine whom to collaborate with in certain situations. Rather than reporting families, the nurse would work with families to help meet their needs if food is not allowed in the room. The nurse would respect the values of clients and not seek to impose any on the clients. Creating a culture of trust is a system change that is implemented by the administration.
What nursing intervention is appropriate for a client with dry and cracked feet?
A) Provide slippers for the client to wear at all times
B) Soak the client’s feet in water several times daily
C) Apply lotion to the client’s feet after bathing
D) Massage the client’s feet daily
C) Apply lotion to the client’s feet after bathing
Rationale: For clients with dry and cracked feet, the nurse should apply lotion to the client’s feet after the client’s bathing time. Providing slippers and massaging the client’s feet will not heal dry and cracked feet. Soaking the client’s feet in water without any added moisturizers may make the client’s condition worse.
A client who is living independently but needs skilled nursing services may take advantage of what type of healthcare?
A) Long-term care
B) Home healthcare
C) Telehealth
D) Assisted living
B) Home healthcare
Rationale: Home healthcare provides a variety of medical, therapeutic, and non-medical services, such as wound care, dietary counseling, physical therapy, occupational therapy, skilled nursing services, and homemaker services. These services are available in private homes from healthcare professionals. Telehealth would not be adequate for providing skilled nursing services. Assisted living facilities do not typically include skilled nursing services. One aspect of long-term care is skilled nursing services, but the clients do not live independently.
The nurse is caring for a 3-year-old child who is in the hospital for the first time. The child appears frightened and is clinging to her parents. What action can the nurse take to help the child feel more secure if the child needs to stay at the hospital without her parents?
A) Stay with the child when the parents go home
B) Have the parents bring comfort items from home to leave with the child
C) Keep dangerous medications and equipment out of the child’s reach
D) Make sure the child wears proper identification at all times
B) Have the parents bring comfort items from home to leave with the child
Rationale: To help a child feel more secure, the nurse can suggest that parents bring in a few comfort items the child is familiar with, such as photos, a favorite blanket, or a favorite toy. Having the nurse stay with the child at all times once the parents have left is not practical and could cause harm to other clients under the nurse’s care. Although the nurse should keep dangerous medications and equipment out of the child’s reach and make sure the child wears proper identification at all times, these actions will likely not help the child feel more secure.
The nurse is providing care to a pregnant client who has type 2 diabetes mellitus. The client has asked about how the medications she is taking will affect her fetus. How should the nurse respond?
A) “The medications you are taking will not adversely affect your fetus. You should continue taking them as you did before your pregnancy.”
B) “The medications you are taking have a risk of causing fetal defects. You should stop taking your medications while you are pregnant.”
C) “The medications you are taking will not work as well when you are pregnant, so you should increase the dose of your medications.”
D) “If you have any concerns about how your medication will affect your fetus, you should talk to your primary care physician.”
D) “If you have any concerns about how your medication will affect your fetus, you should talk to your primary care physician.”
Rationale: Encouraging the client to change medication dosages, stop taking medications, or continue with the present treatment plan after a major change in health status is outside the nursing scope of practice. If the client has concerns about medications, she should talk to her primary care physician or other provider. Depending on the medication and the client’s health status, the provider may recommend increasing, decreasing, or stopping treatment during pregnancy, or the client may continue the present treatment plan. However, the nurse can reinforce any teaching provided by the physician.
Which action by a nurse would require immediate intervention by another healthcare team member?
A) Recapping a needle using the scoop method.
B) Recapping a needle with the use of a hemostat.
C) Recapping a needle while holding the cap.
D) Disposing of a needle in the sharps container.
C) Recapping a needle while holding the cap.
Rationale: When working with used or contaminated sharps, nurses will employ extra precautions so as to avoid unnecessary injuries. Needles that have been used will be disposed of in an appropriate sharps container. If sharps do need to be recapped, this should be done with the use of another device (such as a hemostat), or with the scoop method. Nurses should never hold the cap in one hand while trying to guide the tip of the needle into the cap with the other–this method substantially increases the risk of a sharp-related injury.
A complaint about unsafe working conditions should be reported to which agency?
A) Occupational Safety and Health Administration
B) National Institute for Occupational Safety and Health
C) State board of nursing
D) American Nurses Association
A) Occupational Safety and Health Administration
Rationale: OSHA enforces the rights of workers to have a safe work environment. Therefore, complaints about unsafe work conditions should be filed with OSHA. NIOSH conducts research to provide advances in safety. State boards of nursing ensure that nurses are prepared and competent to provide safe nursing care. The American Nurses Association is a professional organization for nurses.
The nurse working in a healthcare setting is charged with inappropriate delegation after asking an unlicensed assistive personnel (UAP) to change the IV bag for a client. To which agency should this action be reported?
A) Board of nursing
B) Occupational Health Safety Network
C) Occupational Health and Safety Administration
D) Health Hazard Evaluation Program
A) Board of nursing
Rationale: The state board of nursing has established procedures for reporting errors and violations made by licensed nurses and acts to investigate those reports. Complaints can include unsafe nursing practices, such as inappropriate delegation. The other agencies do not investigate nursing errors.
A hospital has had higher than average reports of client handling and movement injuries. What could the nurse advocate for that could most help reduce the number of client handling injuries?
A) Keep the clients restricted to bed
B) Encourage clients to lose weight
C) Hire more nurses
D) Purchase lifting devices
A) Keep the clients restricted to bed
Rationale: Client handling and movement injuries are one of the leading causes of work-related injuries for nurses. Resources such as lifting devices, training, and lift teams can potentially reduce the number of occupational injuries of healthcare workers. Keeping the clients stationary would increase complications and slow the healing process. Encouraging clients to lose weight would not reduce injuries. Unless the hospital is understaffed, hiring more nurses would not help reduce injuries. Instead, nurses need to form lift teams to help reduce injuries.
The home healthcare nurse is traveling to a client’s home for the first time. What observation would suggest a safety hazard for the nurse?
A) Neighbor walking a dog on a leash
B) Porch steps that are broken and rotting
C) Client medications on the kitchen counter
D) Absence of street lights in the neighborhood
B) Porch steps that are broken and rotting
Rationale: Unhygienic or dangerous surroundings, such as broken and rotting porch steps, may pose a safety hazard for the nurse. Unrestrained and hostile animals may pose a safety threat, but a neighbor walking a dog on a leash is not a safety hazard for the nurse. Client medications on the kitchen counter may be a safety hazard if small children are present in the home, but this does not pose a safety hazard for the nurse. The nurse should only make home visits during daylight hours to maintain safety, so the absence of street lights in the neighborhood should not affect the nurse.
An experienced nurse has accepted a new position in the mental health unit after working in the medical-surgical floor for the past 4 years. What training would be beneficial for the nurse to refresh before starting her new position?
A) How to properly use respirators
B) How to prevent needlestick injuries
C) How to manage aggressive behaviors
D) How to safely lift and move clients
C) How to manage aggressive behaviors
Rationale: The nurse is exposed to a higher risk of injuries from assaults by clients or their families in a mental health unit compared to a medical-surgical unit. Therefore, the nurse may benefit from receiving training related to managing aggressive behaviors. Because of her experience on the medical-surgical unit, the nurse is already likely familiar with how to safely lift and move clients and how to prevent needlestick injuries. Knowing how to use a respirator is more important for an infectious disease unit, not a mental health unit.
