Study Guide Ch. 10

Question 1

RACE

Answer 1

Rescue, Alarm, Confine, Extinguish

Question 2

CDC

Answer 2

Centers for Disease Control and Prevention

Question 3

OSHA

Answer 3

Occupational Safety and Health Administration

Question 4

PASS

Answer 4

Pull, Aim, Squeeze, and Sweep

Question 5

SRD

Answer 5

Safety Reminder Device

Question 6

6. The older adult tells the nurse that he is having trouble reading the labels on his medication bottles. What is the best strategy that the nurse could suggest to reduce the risk of an accidental medication error?

A. Recommend that a younger family member assist in handling the pills.
B. Teach the patient to use a medication organizer to manage the medication.
C. Tell the patient to have the pharmacist read the label information to him.
D. Assist the patient to memorize the shape and color of each pill.

Answer 6

B. Teach the patient to use a medication organizer to manage the medication.

Question 7

7. In which clinic setting is the nurse most likely to need knowledge of how to apply safety reminder devices (SRDs) and manage the care of these patients?

A. Pediatric walk-in clinic
B. Outpatient surgery clinic
C. Mental health walk-in clinic
D. Adult ambulatory care clinic

Answer 7

C. Mental health walk-in clinic

Question 8

8. A confused patient is yelling at the unlicensed assistive personnel (UAP). As the nurse enters the room, the patient throws the food tray at the UAP. What would the nurse do first?

A. Ask the UAP to explain what is happening with the patient.
B. Instruct the UAP to move toward the door and then slowly shut it.
C. Slowly walk toward the patient and use a gentle touch to soothe him.
D. Calmly talk to the patient and respectfully address him by name.

Answer 8

D. Calmly talk to the patient and respectfully address him by name.

Question 9

9. The nurse is teaching a new group of UAP how to evacuate residents from a long-term care facility in case of a fire or other emergency. Which item would be needed for the universal carry method?

A. A blanket
B. A wheelchair
C. A stretcher
D. A mechanical lift

Answer 9

A. A blanket

Question 10

10. The older adult residents in a nursing home must be evacuated because the facility is at risk for flooding and damage due to a hurricane that will pass through the area in several days.
    The nurse is assigned to keep a log to document the events. Which information is most important to record? Select all that apply.

A. How each resident was transported
B. Names of residents
C. Where the residents were sent
D. What personal belongings were sent
E. Who transported each resident
F. Notification of family members and health care providers (HCPs)

Answer 10

A. How each resident was transported
B. Names of residents
C. Where the residents were sent
E. Who transported each resident
F. Notification of family members and health care providers (HCPs)

Question 11

11. In the event of a mercury spill, what is the priority nursing action?

A. Evacuate everyone from the room.
B. Close the interior doors and open windows.
C. Vacuum the mercury and the glass shards.
D. Mop the floor with hot water and soap.

Answer 11

A. Evacuate everyone from the room.

Question 12

12. The nurse is caring for a patient who relies on mechanical ventilation. The nurse hears a fire alarm and flames are visible in a back corridor. What would the nurse do first?

A. Seek assistance to move the patient and the ventilator to safety.
B. Turn off the oxygen supply and provide manual respiratory support.
C. Close the patient’s door, call 911, and fight the fire in the corridor.
D. Delegate the UAP to move ambulatory patients toward the exit.

Answer 12

D. Delegate the UAP to move ambulatory patients toward the exit.

Question 13

13. The nurse is planning to teach a community group about fire safety in the home. Which information would be included in the presentation? Select all that apply.

A. No smoking by the patient, family, or visitors in areas where oxygen is used.
B. Use safety matches to light candles or fireplaces.
C. Install fire alarms, smoke detectors, and carbon monoxide detectors.
D. Practice fire escape routes from each room and practice exit drills.
E. Use one electrical circuit to facilitate monitoring of cords and appliances.
F. Cover electrical cords with a secure carpet to prevent falls.

Answer 13

A. No smoking by the patient, family, or visitors in areas where oxygen is used.
C. Install fire alarms, smoke detectors, and carbon monoxide detectors.
D. Practice fire escape routes from each room and practice exit drills.

Question 14

14. An older adult patient in a long-term care facility has been wandering around outside of the room during the late evening hours. The patient has a history of falls. How would the nurse intervene?

A. Obtain an order for a bed and chair alarm.
B. Keep the light on and play the television all night.
C. Put up the side rails and frequently check on the patient.
D. Have the family come to check on the patient at night.

Answer 14

A. Obtain an order for a bed and chair alarm.

Question 15

15. The nurse applies a gait belt to a male patient of average build who has some weakness on the left side. How does the nurse position herself before assisting the patient to ambulate?

A. On the patient’s left side and holding the weak left arm.
B. On the patient’s right side and holding the front of the gait belt.
C. On the patient’s left side and holding the back of the gait belt.
D. On the patient’s right side and holding one arm around his waist.

Answer 15

C. On the patient’s left side and holding the back of the gait belt.

Question 16

16. The nurse is considering the use of an SRD to prevent a patient from self-injury. When using an SRD, what would the nurse do? Select all that apply.

A. Obtain an order from the HCP for the SRD.
B. Explain the purpose of the SRD to the patient.
C. Explain the purpose of the SRD to the family.
D. Obtain consensus of nursing staff for type of SRD.
E. Exhaust all alternatives before using an
SRD.

Answer 16

A. Obtain an order from the HCP for the SRD.
B. Explain the purpose of the SRD to the patient.
C. Explain the purpose of the SRD to the family.
E. Exhaust all alternatives before using an
SRD.

Question 17

17. The nurse notices smoke coming from the wastebasket in a patient’s room. Upon entering the room, the nurse sees a fire that is starting to flare up. What would the nurse do first?

A. Extinguish the fire.
B. Remove the patient from the room.
C. Close the door to the room.
D. Turn off all electrical equipment.

Answer 17

B. Remove the patient from the room.

Question 18

18. Which occurrence is most likely to be investigated as a “sentinel event”?

A. Patient leaves the hospital against medical advice because she gets angry with the nurse.
B. An older patient sustains a broken arm related to the use of an SRD.
C. A nurse is 2 hours late administering routine scheduled medications.
D. During a follow-up phone call, a patient reports that care in the hospital was poor.

Answer 18

B. An older patient sustains a broken arm related to the use of an SRD.

Question 19

19. The nurse is conducting a fall risk assessment on an older adult patient who is moving into an assisted living center. Which questions would the nurse ask? Select all that apply.

A. “Have you had any falls in the past year?”
B. “Are you able to independently get up after a fall?”
C. “Do you feel unsteady when you stand up?”
D. “Are you able to independently walk from room to room?”
E. “What medications are you taking?”
F. “Do you use a cane or other assistive device?”

Answer 19

A. “Have you had any falls in the past year?”
C. “Do you feel unsteady when you stand up?”
D. “Are you able to independently walk from room to room?”
E. “What medications are you taking?”
F. “Do you use a cane or other assistive device?”

Question 20

20. The nurse is giving instructions to the UAP about patient safety and fall prevention. What would the nurse tell the UAP about helping the older adult patient to go to the bathroom?

A. “Help the patient whenever she needs help.”
B. “Ask her if she wants to walk or use the bedpan.”
C. “Have her put on her glasses before getting up.”
D. “Help her to the commode chair if she seems weak.”

Answer 20

C. “Have her put on her glasses before getting up.”

Question 21

21. For the care of a patient who has an SRD in place, which task can be delegated to a UAP?

A. Observe for circulation distal to the SRD.
B. Check for respiratory effort and breathing.
C. Change position every 2 hours.
D. Determine when the SRD can be removed.

Answer 21

C. Change position every 2 hours.

Question 22

22. Which instructions would be given to the UAP who is assigned to assist in the care of a patient who is being treated with internal radiation?

A. “Do not go into the room unless the patient uses the call bell.”
B. “Help children to don a lead shield apron before entering the room.”
C. “Wear a mask, eye shield, and isolation gown when entering the room.”
D. “Wear your personal dosimeter during care or when handling patient items.”

Answer 22

D. “Wear your personal dosimeter during care or when handling patient items.”

Question 23

23. A patient begins to have a grand mal seizure. What is the priority action?

A. Monitor the patency of the airway.
B. Protect against falls and other injuries.
C. Suction the mouth to prevent aspiration.
D. Gently insert an oral airway between the teeth.

Answer 23

A. Monitor the patency of the airway.

Question 24

24. The nurse is talking to a young mother who has an infant who has just started to crawl. Based on knowledge of growth and development, which safety issue is currently the most important to discuss with the mother?

A. What to do when using pots and pans on the stove
B. How to ensure backyard pool safety measures
C. How to manage electrical sockets and cords
D. Where to obtain safety labels for cleaning products

Answer 24

C. How to manage electrical sockets and cords

Question 25

25. Which newly obtained piece of equipment creates the greatest risk for falls for an older adult?

A. Gait belt
B. Prescription lenses
C. Safety bar in shower
D. Walker

Answer 25

B. Prescription lenses

Question 26

26. The postoperative patient demonstrates some mild dizziness and mild shortness of breath when moving from sitting to standing position. Which action would the nurse perform first?

A. Assist the patient to get into bed.
B. Assist the patient to sit back down.
C. Check vital signs and assess symptoms.
D. Call the provider for an order for oxygen.

Answer 26

B. Assist the patient to sit back down.

Question 27

27. The patient reports dizziness when standing up too fast. Which over-the-counter medication is most likely to be contributing to the patient’s orthostatic hypotension?

A. No aspirin pain reliever
B. Antihistamine
C. Vitamin supplement
D. Medicated cough drop

Answer 27

B. Antihistamine

Question 28

28. An infant has a wound with a dressing on the left upper arm. He repeatedly attempts to remove the dressing. Which SRD would the nurse select?

A. Mummy wrap
B. Wrap jacket
C. Bilateral wrist SRDs
D. Right elbow SRD

Answer 28

D. Right elbow SRD

Question 29

29. A mother brings her alert and playful child to the clinic because she “found him playing with this empty bottle of baby aspirin.” Which question is the most important to ask the mother?

A. “Has he ever done anything like this before?”
B. “How many times has he vomited since the ingestion?”
C. “How many pills do you think were in the container?”
D. “Did you contact poison control before you drove to the clinic?”

Answer 29

C. “How many pills do you think were in the container?”

Question 30

30. A patient with a latex allergy is exposed to latex. Which sign or symptom is cause for the greatest concern?

A. Hives
B. Laryngeal edema
C. Runny eyes and nose
D. Localized swelling

Answer 30

B. Laryngeal edema

Question 31

31. Before the nurse can intervene, the UAP pushes contaminated material into an overfilled sharps container and sustains a puncture wound. What would the nurse do first?

A. Tell the UAP to immediately report to the infection-control nurse.
B. Assist the UAP to scrub the wound with copious amounts of soap and water.
C. Report the UAP for improper handling of hazardous material.
D. Dispose of the sharps container to prevent any additional injuries to others.

Answer 31

B. Assist the UAP to scrub the wound with copious amounts of soap and water.

Question 32

32. The nurse started a new job in a small long-term care facility in a rural area. The back exit hallway is being used as a storage area while a new storage area is being planned. What would the nurse do first?

A. Report the facility for unsafe conditions.
B. Express unwillingness to work in unsafe conditions.
C. Review the facility’s policies.
procedures for emergencies.
D. Check the building for other safety issues.

Answer 32

C. Review the facility’s policies.
procedures for emergencies.

Question 33

33. The nurse is sitting at the front desk at a walk-in clinic. A patient comes in and reports fever, malaise, and muscle aches with a rash on the tongue, mouth, and throat. The nurse notes pustules on the patient’s palms. What would the nurse do first?

A. Notify the public health department.
B. Isolate the patient.
C. Put on personal protective equipment
(PPE).
D. Call the HCP to triage the patient.

Answer 33

B. Isolate the patient.

Question 34

34. It is suspected that a patient has been exposed to cyanide gas. The nurse is alert for which symptom?

A. Erratic behavior
B. Nausea and vomiting
C. Respiratory distress
D. Vesicle formation

Answer 34

C. Respiratory distress

Question 35

35. The nurse is reviewing the disaster preparedness plan for a small nursing home. What would be included in the plan? Select all that apply.

A. Emergency treatment for the most critically injured
B. Possible admission to a hospital or transfer to a temporary shelter
C. Log to document residents’ names and locations
D. System to notify families and providers
E. Designation of an area for decontamination 6.
F. Method of patient identification, such as a bracelet or picture ID

Answer 35

B. Possible admission to a hospital or transfer to a temporary shelter
C. Log to document residents’ names and locations
D. System to notify families and providers
F. Method of patient identification, such as a bracelet or picture ID

Question 36

36. The nurse is working in a local health department and has noted an unusually large number of phone calls about food-borne illness. Which question is the nurse most likely to ask callers to differentiate the possible involvement of the bioterrorist agent that causes botulism from other more common causes of food-borne illness?

A. In addition to gastrointestinal symptoms, have you had drooping eyelids or difficulty swallowing or speaking?
B. Have you experienced a low-grade fever, sweating, fatigue, and a nonproductive cough?
C. How soon after eating did the abdominal cramping, vomiting, and diarrhea start?
D. Have you had fever, malaise, and muscle aches with a rash on the tongue, mouth, throat, and palms?

Answer 36

A. In addition to gastrointestinal symptoms, have you had drooping eyelids or difficulty swallowing or speaking?

Question 37

37. The nurse is preparing to give an intramuscular injection to a patient. What factors would increase the risk of needlestick injury to the nurse? Select all that apply.

A. Using a needleless device
B. Disposing the needle device in the needle disposal container
C. Applying a Band-Aid to the injection site immediately after administering injection
D. Using a new type of safety device injection system
E. Recapping the needle after the injection
F. Cleansing the skin with an alcohol swab after uncapping the needle

Answer 37

C. Applying a Band-Aid to the injection site immediately after administering injection
D. Using a new type of safety device injection system
E. Recapping the needle after the injection
F. Cleansing the skin with an alcohol swab after uncapping the needle

Question 38

38. The patient with mild cognitive impairment is being discharged from the hospital with several new medications. Which action by the nurse would be most effective in reducing the risk of accidental poisoning by medication misuse?

A. Teach the patient the names, doses, potential side effects, and indication for use for each medication.
B. Request that the patient have their adult son come to safely set up the medications each day.
C. Teach the patient how to use a medication box and reminders.
D. Teach the patient how to organize the medications on the day of discharge.

Answer 38

C. Teach the patient how to use a medication box and reminders.

Question 39

39. The hospitalized patient is confused and has a history of falls. Which actions would the nurse take to help avoid the use of SRDs? Select all that apply.

A. Review the patient’s medication list.
B. Assign the patient to a quiet room far from the nurses’ station.
C. Use a sitter if needed if family members are not available.
D. Use a bed alarm.
E. Restrict visitors because the patient becomes upset when they leave.
F. Use relaxation techniques such as massage or music to create a calm atmosphere for the patient.

Answer 39

A. Review the patient’s medication list.
C. Use a sitter if needed if family members are not available.
D. Use a bed alarm.
F. Use relaxation techniques such as massage or music to create a calm atmosphere for the patient.