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The nurse's first action after discovering an electrical fire in a patient's room is to:
1. Activate the fire alarm
2. Confine the fire by closing all doors and windows
3. Remove all patients in immediate danger
4. Extinguish the fire by using the nearest fire extinguisher
3. Remove all patients in immediate danger
Follow the acronym RACE. The first step, R, is to rescue and remove all patients in immediate danger.
R.emove all patients in immediate danger
A.ctivate the fire alarm
C.onfine the fire by closing all doors and windows
E.xtinguish the fire by using the nearest fire extinguisher
A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2 year old son drank. Which of the following is the most important instruction the nurse gives to this parent?
1. Give the child milk
2. Give the child syrup of ipecac
3. Call the poison control center
4. Take the child to the emergency department
3. Call the poison control center
A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning.
The nursing assessment on a 78 year old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?
1. Activity intolerance
2. Impaired bed mobility
3. Acute pain
4. Risk for falls
4. Risk for falls
For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls.
A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent?
1. Home accidents
2. Physiological changes of aging
3. Poisoning and child abduction
4. Automobile accidents, suicide, and substance abuse
4. Automobile accidents, suicide, and substance abuse
Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs.
The nurse found a 68 year old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.)
1. Insert a urinary catheter
2. Leave a night light on in the bathroom
3. Ask the physician to order a restraint
4. Keep the bed in low position with upper and lower side rails up
5. Assign a staff member to stay with the patient
6. Provide scheduled toileting during the night shift
7. Keep the pathway from the bed to the bathroom clear
2. Leave a night light on in the bathroom
6. Provide scheduled toileting during the night shift
7. Keep the pathway from the bed to the bathroom clear
Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury.
The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.)
1. Contact the nursing supervisor
2. Restrict the family's visiting privileges
3. Ask the family to stay with the patient if possible
4. Inform the family of the risks associated with side rail use
5. Thank the family for being conscientious and put the four rails up
6. Discuss alternatives with the family that are appropriate for this patient.
3. Ask the family to stay with the patient if possible
4. Inform the family of the risks associated with side rail use
6. Discuss alternatives with the family that are appropriate for this patient.
The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presences of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided.
A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order.
1. Explain what you plan to do
2. Wrap a limb restraint around wrist or ankle with soft part toward skin and secure
3. Determine that restraint alternatives fail to ensure patient's safety
4. Identify the patient using proper identifier
5. Pad the patient's wrist
3. Determine that restraint alternatives fail to ensure patient's safety
4. Identify the patient using proper identifier
1. Explain what you plan to do
5. Pad the patient's wrist
2. Wrap a limb restraint around wrist or ankle with soft part toward skin and secure
A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation?
1. Begin cardiopulmonary respiration
2. Restrain the child to prevent injury
3. Place a tongue blade over the tongue to prevent aspiration
4. Clear the area around the child to protect the child from injury
4. Clear the area around the child to protect the child from injury
Once a seizure begins, you need to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth. See the Skills in the chapter for more information.
A 62 year old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that:
1. A safe environment promotes patient activity
2. Assessment focuses on environmental factors only
3. Teaching home safety is difficult to do in the hospital setting
4. Most accidents in the older adult are caused by lifestyle factors
1. A safe environment promotes patient activity
Older adults are frequently fearful of falling and thus often limit activity. A safe environment, which decreases the risk of a fall, promotes patient activity.
A fragile, 87 year old nursing home resident is admitted to the hospital with dehydration and increased confusion. The patient has upper limb restraints to prevent her from pulling out her nasogastric tube. What instructions does the nurse give to NAPs?
The use of restraints is associated with serious complications resulting from immobilization such as pressure ulcers, pneumonia, constipation, and incontinence. In some cases death has resulted because of restricted breathing and circulation. The restraint itself could injure the underlying skin. Routine checks are required to prevent or decrease these complications. The NAP needs to notify the nurse if there is a change in skin integrity, circulation, or patient's breathing and provide range of motion, nutrition and hydration, skin care, toileting, and opportunities for socialization at least every 2 hours.
The nursing assessment of an 80 year old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to:
1. Place a bed alarm device on the bed
2. Place the patient in a belt restraint
3. Provide one on one observation of the patient
4. Apply wrist restraints
1. Place a bed alarm device on the bed
Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently.
To ensure the safe use of oxygen in the home by a patient which of the following teaching points does the nurse include? (Select all that apply.)
1. Smoking is prohibited around oxygen
2. Demonstrate how to adjust the oxygen flow rate based on patient symptoms
3. Do not use electrical equipment around oxygen
4. Special precautions may be required when traveling with oxygen
1. Smoking is prohibited around oxygen
3. Do not use electrical equipment around oxygen
4. Special precautions may be required when traveling with oxygen
When oxygen is in use, precautions need to be taken to prevent fire and protect the patient. Patients need to be taught precautions, which include posting "Oxygen in Use" signage, not using oxygen around electrical equipment or flammable products, properly handling oxygen cylinders/containers, ensuring that tubing is unobstructed, not adjusting liter flow without a physician's order, and taking precautions when traveling with oxygen.
How does the nurse support a culture of safety? (Select all that apply.)
1. Completing incident reports when appropriate
2. Completing incident reports for a near miss
3. Communicating product concerns to an immediate supervisor
4. Identifying the person responsible for an incident
1. Completing incident reports when appropriate
2. Completing incident reports for a near miss
3. Communicating product concerns to an immediate supervisor
Completing incident reports for actual and near-miss events helps the facility track information and identify trends and patterns that need to be addressed. Communicating product concerns to a responsible supervisor allows the facility to further investigate and determine if additional action is required.
You are admitting Mr. Jones, a 64 year old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an anti-hypertensive and a diuretic. Currently he exhibits left sided neglect and problems with spacial and perceptual abilities and is impulsive. He has a moderate left sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an IV line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.)
1. Smokes a pack a day
2. Used a cane to walk at home
3. Takes anti-hypertensive and diuretics
4. History of recent fall
5. Neglect, spatial and perceptual abilities
6. Requires assistance with activity, unsteady gait
7. IV line, urinary catheter
3. Takes anti-hypertensive and diuretics
4. History of recent fall
5. Neglect, spatial and perceptual abilities
6. Requires assistance with activity, unsteady gait
7. IV line, urinary catheter
Smoking is not a risk factor for falls. Because the patient used the cane at home, it is not a current risk factor for falls. Risk is determined by his current status.
At 3 AM the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first?
1. Prepare of an influx of patients
2. Contact the American Red Cross
3. Determine how to restore essential services
4. Evacuate patients per the usual disaster plan
1. Prepare of an influx of patients
The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the disaster plan. Patients may need to be evacuated but not initially. The American Red Cross is not contacted initially. Determination of how to restore essential services is part of the disaster plan and is determined before an actual event.
