NCLEX - W3 - Safety Flashcards
A nurse is caring for a 78-year-old patient who has a history of falls. Which of the following interventions is the most appropriate for this patient?
a. Place the patient in a room far from the nurses’ station.
b. Keep the bed in the lowest position with the side rails up.
c. Encourage the patient to wear socks to bed.
d. Administer a sedative at bedtime.
Answer: b. Keep the bed in the lowest position with the side rails up.
Rationale:
Keeping the bed in the lowest position reduces the distance the patient could fall. Side rails can help to prevent the patient from rolling out of bed, but it’s important to assess the patient’s cognitive status and risk of entrapment.
A nurse is teaching a patient about home safety. Which of the following statements by the patient indicates a need for further teaching?
a. “I will keep my medications in a locked cabinet.”
b. “I will use a nonskid mat in the shower.” c. “I will leave my throw rugs in place.”
d. “I will install grab bars in the bathroom.”
Answer: c. “I will leave my throw rugs in place.”
Rationale: Throw rugs are a common cause of falls, especially for older adults. The patient should be instructed to remove them or secure them with nonskid backing.
A nurse is caring for a patient who is confused and agitated. Which of the following actions should the nurse take first?
a. Apply restraints to the patient.
b. Administer a sedative to the patient.
c. Attempt to reorient the patient to their surroundings.
d. Move the patient to a room closer to the nurses’ station.
Answer: c. Attempt to reorient the patient to their surroundings.
Rationale: Restraints should only be used as a last resort. Before considering restraints, the nurse should try less restrictive interventions, such as reorientation, providing a calm environment, and enlisting the help of family or friends.
A nurse is assessing a patient’s risk for falls. Which of the following factors is the most important to consider?
a. The patient’s age
b. The patient’s gender
c. The patient’s history of falls
d. The patient’s weight
Answer: c. The patient’s history of falls
Rationale: A history of falls is the most significant predictor of future falls. Other risk factors include age, medications, mobility impairment, and cognitive status.
A nurse is teaching a group of parents about safety measures for toddlers. Which of the following statements by a parent indicates an understanding of the teaching?
a. “I will keep all cleaning supplies in the bathroom cabinet.”
b. “I will make sure my toddler always wears a helmet when riding a tricycle.”
c. “I will let my toddler play with small toys unsupervised.”
d. “I will leave pots and pans on the stove within reach.”
Answer: b. “I will make sure my toddler always wears a helmet when riding a tricycle.”
Rationale: Toddlers are at high risk for falls, and head injuries can be serious. A helmet can help to protect the toddler’s head.
A nurse is caring for a patient who is receiving oxygen therapy. Which of the following safety measures is most important?
a. Keep the oxygen tank away from open flames.
b. Ensure the patient has adequate ventilation.
c. Monitor the patient’s oxygen saturation levels.
d. Change the oxygen tubing every 24 hours.
Answer: a. Keep the oxygen tank away from open flames.
Rationale: Oxygen is flammable, and an open flame could cause a fire or explosion.
A nurse is witnessing a patient signing a consent form for a procedure. Which of the following actions by the nurse is appropriate?
a. Explain the procedure to the patient.
b. Ensure the patient understands the risks and benefits of the procedure.
c. Sign the consent form as a witness.
d. Advise the patient to sign the form even if they have questions.
Answer: c. Sign the consent form as a witness.
Rationale: The nurse’s role in obtaining consent is to witness the patient’s signature. The physician is responsible for explaining the procedure and ensuring the patient understands the risks and benefits
A nurse is preparing to administer a medication to a patient. Which of the following is the most important step the nurse should take to prevent a medication error?
a. Check the patient’s identification bracelet.
b. Ask the patient to state their name and date of birth.
c. Verify the medication order with another nurse.
d. Use a bar code scanner to identify the medication.
Answer: a. Check the patient’s identification bracelet.
Rationale: The most critical step in preventing medication errors is to correctly identify the patient. The nurse should use two identifiers, such as the patient’s name and date of birth or medical record number.
A nurse is caring for a patient who has a latex allergy. Which of the following precautions should the nurse take?
a. Wear latex gloves when providing care. b. Use latex-free equipment and supplies. c. Place the patient in a private room.
d. Restrict visitors who have latex allergies.
Answer: b. Use latex-free equipment and supplies.
Rationale: Patients with latex allergies can have severe reactions to latex exposure. The nurse should use latex-free gloves, equipment, and supplies to prevent an allergic reaction.
A nurse is caring for a patient who is at risk for seizures. Which of the following actions should the nurse take?
a. Place the patient in a private room. b. Pad the side rails of the bed. c. Keep a tongue blade at the bedside. d. Restrict the patient’s activity.
Answer: b. Pad the side rails of the bed.
Rationale: Padding the side rails can help to prevent injury if the patient has a seizure.
A nurse is caring for a patient who is receiving a blood transfusion. Which of the following actions should the nurse take if the patient develops signs of a transfusion reaction?
a. Slow the infusion rate.
b. Stop the transfusion immediately.
c. Administer an antihistamine.
d. Notify the physician.
Answer: b. Stop the transfusion immediately.
Rationale: A transfusion reaction can be life-threatening. The nurse should stop the transfusion immediately and notify the physician
A nurse is caring for a patient who has a history of violence. Which of the following actions by the nurse is appropriate?
a. Approach the patient in a calm and assertive manner.
b. Stand close to the patient when speaking to them.
c. Avoid making eye contact with the patient.
d. Touch the patient to reassure them.
Answer: a. Approach the patient in a calm and assertive manner.
Rationale: Approaching the patient in a calm and assertive manner can help to de-escalate the situation.
Which of the following is a “never event” according to the Centers for Medicare and Medicaid Services (CMS)?
a. Stage I pressure ulcer
b. Fall with no injury
c. Surgery on the wrong body part
d. Urinary tract infection
Answer: c. Surgery on the wrong body part
Rationale:
“Never events” are serious and preventable adverse events that should never occur in a healthcare setting. Surgery on the wrong body part is a “never event.”
A nurse is teaching a patient about using a cane for ambulation. Which of the following instructions should the nurse include in the teaching?
a. “Hold the cane on the same side as your affected leg.”
b. “Move the cane forward first, then your affected leg.”
c. “Lean on the cane for support when standing up.”
d. “Adjust the cane so that it is level with your waist.”
Answer: b. “Move the cane forward first, then your affected leg.”
Rationale: The patient should move the cane forward first, then the affected leg, and finally the unaffected leg.
Which of the following is an example of a patient-inherent accident?
a. A patient falls out of bed because the side rails are not raised.
b. A patient develops a pressure ulcer because they are not turned regularly.
c. A patient burns themselves with hot coffee because they are not paying attention.
d. A patient is injured by a defective piece of equipment.
Answer: c. A patient burns themselves with hot coffee because they are not paying attention.
Rationale: A patient-inherent accident is an accident that is caused by the patient’s own actions.
Answer:
c. A patient burns themselves with hot coffee because they are not paying attention.
Rationale:
A patient-inherent accident is an accident that is caused by the patient’s own actions.
