Deck 3 Module 51 Safety

Question 1

The nurse is caring for a client who is prone to falls. Which nursing diagnosis would be most appropriate for this client?

A) Risk for Injury
B) Risk for Suffocation
C) Deficient Knowledge
D) Risk for Disuse Syndrome

Answer 1

A) Risk for Injury

Rationale: Risk for Injury is a state in which the individual is at risk as a result of environmental conditions such as a fall. Deficient Knowledge deals with injury prevention. Risk for Disuse Syndrome is a deterioration of a body system as the result of prescribed or unavoidable musculoskeletal inactivity. Risk for Suffocation occurs when inadequate air is available for inhalation.

Question 2

A nurse manager is assessing the hospital environment in order to decrease the risk for client falls. Which is the best intervention to decrease the risk of client falls?

A) Keep the call button within reach at all times.
B) Read label directions.
C) Keep electrical cords under the bed.
D) Clean the environment of clutter.

Answer 2

D) Clean the environment of clutter.

Rationale: Keeping the environment tidy and free of clutter will go a long way in preventing falls. The call button should always be within reach of the client, but is not the best way to prevent falls. Electrical cords should be used only if necessary, and the maintenance department can help if any of them present a hazard. Reading label directions will prevent the wrong use of substances given to the client but would not directly prevent falls.

Question 3

A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After applying soft hand 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.

Answer 3

A) Notify the primary healthcare provider.

Rationale: According to the law, the primary healthcare provider must see the client and write a prescription for restraints within 1 hour of application. The nurse would apply the restraints to protect the airway and then immediately notify the primary healthcare provider. 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.

Question 4

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 most appropriate?

A) “We want the public to know we are trying to be safe.”
B) “Clinic staff members require frequent reminders about client safety.”
C) “National safety goals focus on the individual making the error.”
D) “National safety goals seek prevention of injury.”

Answer 4

D) “National safety goals seek prevention of injury.”

Rationale: National Patient Safety Goals are focused on solutions to safety issues and prevention of further injuries. Instead of focusing on the individual who made the error, the goals focus on finding ways to prevent that error from happening again. The staff members should not need to be reminded about safety, as safety should be the culture of health care. Healthcare agencies want the public to know about their safety promotions, but that is not the goal of the program.

Question 5

Several nurses are discussing the Joint Commission’s 2013 National Patient Safety Goals during a staff meeting. Which goal improves the effectiveness of communication among caregivers?
A) Conduct a verification process to confirm the correct procedure.
B) Transmit test results in a timely manner to the appropriate staff member.
C) Review a list of look-alike/sound-alike drugs used in the organization.
D) Use the client’s room number as an identifier.

Answer 5

B) Transmit test results in a timely manner to the appropriate staff member.

Rationale: Transmitting test results in a timely manner to the appropriate staff member improves the effectiveness of communication among caregivers. Using the client’s room number as an identifier is a passive technique that would not improve the accuracy of client identification. Conducting a verification process to confirm that the correct procedure for the correct client is to be performed is a way of improving the accuracy of client identification. Annually reviewing a list of look-alike/sound-alike drugs is done to improve the safety of use of medication in an organization, not to improve effective communication.

Question 6

After completing an assessment, the nurse determines a client is at risk for safety issues. Which data supports the nurse’s conclusion?
Select all that apply.

A) Lives with adult married daughter and family
B) Occasional dizziness with walking
C) Prescribed antihypertensive and pain medication
D) Ingests three meals a day and two snacks
E) Receives an annual ophthalmologic examination

Answer 6

B) Occasional dizziness with walking
C) Prescribed antihypertensive and pain medication

Rationale: Nurses consider safety at all points during the nursing process, and while working to prioritize client needs. Risks to safety include medications that could cause adverse effects such as antihypertensives and pain medication and factors that can impact falls such as mobility issues or balance. Living with family, eating a balanced diet, and having annual eye examinations do not increase the client’s risk for safety issues.

Question 7

The nurse manager is evaluating a staff nurse’s knowledge, skills, and attitudes when addressing safety issues with client care. What observations indicate the nurse is skilled when addressing safety concerns?
Select all that apply.

A) Documents care immediately after providing it
B) Devises methods that enhance teamwork
C) Participates in conflict resolution
D) Recognizes deficiencies between current and best practice
E) Participates in root cause analysis when appropriate

Answer 7

A) Documents care immediately after providing it
E) Participates in root cause analysis when appropriate

Rationale: Skills associated with safety include establishing ways to decrease dependence on memory such as documenting care immediately after providing it and undertaking root cause analysis instead of assigning blame. Devising methods that enhance teamwork and participating in conflict resolution are skills associated with teamwork and collaboration. Recognizing deficiencies between current and best practice is a skill associated with quality improvement.

Question 8

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 utilizing any prescribed eyewear.
C) Utilize side rails on client beds.
D) Keep frequently used items within easy reach.

Answer 8

B) Assess the client’s vision and make sure he is utilizing any prescribed eyewear.
C) Utilize side rails on client beds.
D) Keep frequently used items within easy reach.

Rationale: Assessing the client’s vision and making sure he is utilizing any prescribed eyewear is an appropriate action. Poor and blurry vision increases the client’s risk of falling. Utilizing 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 client gets out of bed. The nurse could include in the plan of care to apply physical restraints only when absolutely necessary for the client’s safety and only by physician’s order.

Question 9

The nurse manager is assessing safe medication administration in preparation for the Joint Commission’s (TJC) visit to the hospital. Which observed action is not recommended according to the TJC’s National Patient Safety Goals?

A) Labeling all medicines that will be administered to the client appropriately
B) Using extra caution with blood thinners
C) Taking care when recording client medicine information
D) Allowing the client to keep home meds at the bedside for use while in the hospital

Answer 9

D) Allowing the client to keep home meds at the bedside for use while in the hospital

Rationale: Safe medicine use is identified as one of the National Patient Safety Goals for hospitals. Solutions to better reach the goal of safe medicine include labeling all medicines, using extra caution with blood thinners, and taking care when recording and communicating client medicine information. It is not appropriate to allow the client to keep home medication at the bedside for use in the hospital.

Question 10

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

Answer 10

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.

Question 11

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) Safety strips are installed in the shower.

Answer 11

D) Safety strips are installed in the shower.

Rationale: Safety strips in the shower can prevent falls. The client who installs the strips 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. The nurse encourages the client to place perishable foods in the refrigerator when arriving home from the store.

Question 12

A home health nurse is teaching an older adult client who has returned home after discharge from the hospital about injury prevention. Which goal would be appropriate to include in this client’s plan of care?

A) The client will take prescribed medication as desired.
B) The client will make uninformed choices when addressing health issues.
C) The client will demonstrate an understanding of all limitations.
D) The client will establish a buddy system.

Answer 12

D) The client will establish a buddy system

Rationale: Establishing a buddy system provides social contact, safeguards against abuse, and offers respite for caregivers. It also provides a way for elders to be checked up on daily. The client may resent imposed limitations and act out in such a way as to cause injury. Making uninformed choices about one’s health could be unsafe instead of safe to the client. A routine should be established for medication administration with correct dosage to prevent the possibility of overdose toxicity.

Question 13

The nurse is conducting a home risk assessment for a family with toddler and preschool-age children. Which finding is considered a safety hazard for this family?

A) Safety plugs in electrical outlets
B) Medications on the kitchen counter
C) Lack of helmets next to bicycles
D) Deadbolt locks on the doors

Answer 13

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. Deadbolt 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.

Question 14

The nurse is conducting a home safety class for a group of parents in the community. Which should the nurse teach families that would contribute to maintaining safety in the home?

A) Remove labels from containers and refill for recycling.
B) Use overloaded outlets only when necessary.
C) Keep plants in the home.
D) Always pull a plug at the plug-in from the wall outlet.

Answer 14

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

rationale: Always pull a plug at the plug-in from the wall outlet. Pulling a plug by its cord can damage the cord and plug unit, creating a dangerous situation. Not knowing which plants are poisonous and which are not may pose a serious problem for children in the home. Always avoid overloading outlets at any time because it may damage the cord and cause a fire. Do not remove container labels or reuse empty containers to store different substances; laws mandate that the labels of all substances specify an antidote.

Question 15

The nurse is caring for a client who will be discharged on a new blood pressure medication which increases the risk of orthostatic hypotension. Which should the nurse include in the discharge teaching to decrease the risk of injury at home?

A) Encourage appropriate lighting.
B) Provide a bedside commode.
C) Rise slowly when getting up.
D) Monitor activity tolerance.

Answer 15

C) Rise slowly when getting up.

Rationale: Orthostatic hypotension can cause dizziness upon rising that can lead to falls. The nurse instructs the client to rise slowly and stand in place for a few seconds until balance is assured. Providing a bedside commode would be appropriate for the client with urinary urgency. Clients with respiratory difficulties or heart ailments would want to monitor their activity tolerance levels. Appropriate lighting would help the client experiencing impaired vision.

Question 16

The home health nurse talking with the parent outside the bathroom door while the toddlers 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.”

Answer 16

A) “Why don’t we talk in the living room?”

Rationale: 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 the toddlers unsupervised in the tub. Taking the children out of the tub and a parent that does not want to leave toddlers alone in the bathroom demonstrates an awareness of risk. There is no risk with bathing the children together.

Question 17

A clinic nurse is preparing a class for new parents on the effects of poor prenatal nutrition. Which is inappropriate to include as an outcome of poor prenatal nutrition?

A) Low birth weight
B) High birth weight
C) Premature birth
D) Altered brain function

Answer 17

B) High birth weight

Rationale: During the prenatal period, poor nutrition can have the following effects: altered brain function in the fetus, low birth weight, premature birth, jaundice, and a risk for learning disorders. High birth weight is not associated with poor prenatal nutrition.

Question 18

The nursing instructor is educating a group of nursing students on sports-related injuries. Which comment made by a student nurse would indicate to the nursing instructor the need for further instruction?

A) “Clients who participate in sports, strenuous exercise, or athletics of any kind should be educated about the dangers of unreported head injuries.”
B) “Adolescents are at the greatest risk for not reporting sports-related injuries.”
C) “Young adults are at the greatest risk for not reporting sports-related injuries.”
D) “Clients who have been injured playing a sport need to be counseled on the risks of unreported concussions.”

Answer 18

C) “Young adults are at the greatest risk for not reporting sports-related injuries.”

Rationale: Clients who participate in sports, strenuous exercise, or athletics of any kind should be educated about the dangers of unreported head injuries. Adolescents are at the greatest risk for not reporting sports-related injuries, but adults should be educated about the dangers as well. Clients who have been injured playing a sport, or even those receiving a sports physical, could be counseled by nurses about the risks of unreported concussions.

Question 19

A nurse educator is teaching nursing students about the application of personal protective equipment (PPE) and emphasizes the importance of appropriate technique when removing the face mask. Which student response indicates appropriate understanding?

A) “I will touch the mask by the strings only.”
B) “I will bend the strip at the top of the mask.”
C) “I will tie the strings in a bow.”
D) “I will loop the ties over the ears.”

Answer 19

A) “I will touch the mask by the strings only.”

Rationale: Touching the mask by the strings for both putting it on and taking it off is the appropriate intervention because the mask is contaminated. Bending the strip at the top of the mask, looping the ties over the ears, and tying the strings in a bow under the chin are all interventions used when applying a mask.

Question 20

The nurse is preparing discharge instructions for a client with an open surgical wound. Which instructions are important for the nurse to include for this client?
Select all that apply.

A) Apply lubricating lotion to the edges of the wound.
B) Notify your doctor if you notice edema, heat, or tenderness at the wound site.
C) Thoroughly irrigate the wound with hydrogen peroxide.
D) Wash hands before and after changing the surgical dressing.
E) Adjust your diet to increase the amount of protein.

Answer 20

B) Notify your doctor if you notice edema, heat, or tenderness at the wound site.
D) Wash hands before and after changing the surgical dressing.
E) Adjust your diet to increase the amount of protein.

Rationale: A client being discharged with an open surgical wound has to be instructed on the detection of infection because the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection and should be reported to the healthcare provider. Increasing protein in the diet will help to enhance wound healing. Hand hygiene before and after dressing changes is essential to decrease the risk of a wound infection. Applying lubricating lotion to the edges of a wound would impede the healing process. Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing.

Question 21

The unit nurse educator is planning to instruct the staff on 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 only once daily.
C) Raise the temperature in the client’s room.
D) Wear a mask for all client care.

Answer 21

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.

Question 22

A nurse is teaching a group in the community ways to decrease the spread of infection. Which measure is the most appropriate for the nurse to include when teaching this group?

A) Use personal protective equipment (PPE) sparingly.
B) Place contaminated linens in a paper bag.
C) Wear gloves at all times.
D) Cover the mouth and nose when sneezing.

Answer 22

D) Cover the mouth and nose when sneezing.

Rationale: The most appropriate area of client education is to cover the mouth and nose when sneezing to prevent airborne droplets from escaping into the air for others to contract in the chain of infection. Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue. PPE is not necessary in the community setting. Gloves are not necessary for clients to wear in the home or community.

Question 23

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 rubber skid-resistant slippers.

Answer 23

D) Have the client wear rubber skid-resistant slippers.

Rationale: Having the client wear rubber skid-resistant slippers 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. The environment should be clutter-free, because any clutter can cause the client to fall. Noise should be kept to a minimum, but turning off alarms would endanger a client.

Question 24

The nurse is planning care for a client who is experiencing confusion. Which action by the nurse ensures safety for this client?

A) Keep the windows in the client’s room closed.
B) Keep the side rails up on the bed when the client is with a staff member.
C) Place the call bell next to the client.
D) Administer ordered medication.

Answer 24

C) Place the call bell next to the client.

Rationale: To prevent falls in the confused client, the nurse should place the call bell next to the client so that the client does not fall trying to reach for it. The bed rails do not need to be up when the client is with a staff member but should be up if the client is alone. Most agency windows are kept closed or are the type that cannot open wide enough to cause injury. Administering ordered medication will not prevent injury to the client.

Question 25

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

Answer 25

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.

Question 26

The nurse is preparing to assess the client’s blood pressure using an electronic monitoring unit and notices that the end of the cord is frayed. Which action by the nurse is most appropriate to prevent harm?

A) Plug the machine in to make sure it works appropriately.
B) Get another machine from the equipment room.
C) Label the machine as broken and notify engineering.
D) Complete an incident report.

Answer 26

C) Label the machine as broken and notify engineering.

Rationale: The best action to prevent injury is to label the machine with information about the frayed cord and notify engineering or the department responsible for equipment safety. The nurse would obtain another machine, but placing the machine with the frayed wire in the equipment room puts another client at risk. The nurse could be jeopardizing personal safety by plugging the machine in. Because no injury has occurred, it would not be appropriate to complete an incident report.

Question 27

A nurse preceptor on the progressive care unit is orienting a newly licensed nurse. Which action taken by the newly licensed nurse requires immediate intervention by the nurse preceptor?

A) The nurse preceptor observes the newly licensed nurse recapping a needle using the scoop method.
B) The nurse preceptor observes the newly licensed nurse recapping the needle with the use of forceps.
C) The nurse preceptor observes the newly licensed nurse picking up contaminated broken glass.
D) The nurse preceptor observes the newly licensed nurse disposing of a needle in the sharps container.

Answer 27

C) The nurse preceptor observes the newly licensed nurse picking up contaminated broken glass.

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 forceps or tongs), 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. According to OSHA, if contaminated glass is broken it should never be picked up by hand; a broom and dustpan or forceps should be used instead. Therefore if the nurse preceptor observes the newly licensed nurse picking up the contaminated broken glass she needs to immediately intervene.