Deck 66: Safety

Question 1

While admitting an adult client for treatment of pneumonia, the nurse discovers that the client has been diagnosed with a seizure disorder. What safety precautions will the nurse put into place for this client? Select all that apply.

A)Request that the client wear a helmet while out of bed.
B)Place suction equipment in the room.
C)Instruct the client to remain in bed at all times.
D)Place the client in a room at the end of the unit to reduce stimuli.
E)Pad the side rails and head board of the bed with blankets.

Answer 1

Place suction equipment in the room.
Pad the side rails and head board of the bed with blankets.

Question 2

The nurse has just placed a bed alarm for a client who is disoriented and has explained its use to the client and his family. Which statement by a family member indicates a need for further information related to fall prevention?

A)"I know this bed alarm will help everyone know if my father tries to get out of bed without help."
B)"I wish this bed alarm would keep my father in bed."
C)"Now that this bed alarm has been installed on my dad's bed, I can go home and get a good night's sleep."
D)"It is so hard watching my father be so confused. I guess this bed alarm is better than nothing."

Answer 2

"Now that this bed alarm has been installed on my dad's bed, I can go home and get a good night's sleep."

Question 3

The nurse is assisting a client to the bathroom when the client begins to have a tonic-clonic seizure. Which is the first thing that the nurse should do at this time?

A)Assist the client back to bed.
B)Take the client's vital signs.
C)Time the seizure.
D)Remove the client's clothing.

Answer 3

Time the seizure.

Question 4

Which statement by an older adult client to the nurse would indicate that the client is being abused? Select all that apply.

A)"I am so cold all of the time because I don't have any warm clothes."
B)"I think I have a sore on my bottom. No one ever cleans me after I use the bathroom."
C)"Please don't tell that lady that brought me here that I showed you my bruises."
D)"I wish I had someone else to bring me here. That lady is a terrible driver."
E)"The lady insists on using the cheap soap to wash my clothes. I hate the smell."

Question 5

The nurse is caring for a client who recently began taking prescribed blood pressure medicine. Which teaching will be most important to this client in the prevention of falls?

A)Wear slipper or non-skid socks when walking.
B)Make sure that the lighting is good when you get out of bed.
C)Use the handrails next to the toilet when getting on and off the toilet.
D)Sit on the side of the bed for at least a minute before getting out of bed.

Question 6

The nurse has been caring for a client who had a tonic-clonic seizure in the hallway of the nursing unit. Which is the first action the nurse should do when the seizure has finished?

A)Reassure the client that a seizure has occurred and that the nurse is providing care.
B)Assist the client to the bathroom to void.
C)Ask the client to report the last memory prior to the seizure.
D)Provide clear liquids to soothe a dry mouth.

Question 7

The nurse is caring for an older adult client who is very confused and is also very thin. The healthcare provider has prescribed wrist restraints to help prevent the client from getting out of bed. Which is the priority for the nurse in applying the wrist restraints to this client?

A)The restraints must be applied loosely to prevent the client from rubbing the skin against the restraint.
B)The nurse must pad the client's wrist bones before applying the wrist restraint.
C)The restraints should be tied to the bed rails to give the nurse easy access to allow quick removal of the restraints if necessary.
D)The nurse should use a vest restraint instead of a wrist restraint to prevent injuring the client's skin.

Question 8

The nurse smells smoke and notes what appears to be a fire in the waste basket in the client's room. Which is the nurse's first action when the fire is noted?

A)Pull the fire alarm.
B)Grab the closest fire extinguisher.
C)Enter the client's room and immediately close the client's door.
D)Assist the client out of the room.

Question 9

The nurse is completing an assessment of an older adult client whose primary caretaker is the grandson. Which would alert the nurse that this client is a possible victim of emotional abuse?

A)The client refuses to look at the grandson.
B)The client reprimands the grandson for being late to the appointment.
C)The client asks the grandson to leave the room during the pelvic examination.
D)The client tells the nurse that the grandson isn't a very good cook.

Question 10

The nurse must restrain a child and knows that a blanket restraint will be best for which child in the nurse's care?

A)A 7-year-old child who has a laceration of the forearm
B)A 5-year-old child who needs to have an IV started in the antecubital space
C)A 3-year-old child who has a laceration of the forehead that needs stitches
D)A 1-year-old child who needs a lumbar puncture to check for meningitis

Question 11

The home health nurse visits an older adult client's home prior to a client's discharge from the hospital to evaluate the home for any safety issues. Which situation if seen by the nurse would constitute the largest safety issue for this client?

A)A trapeze lift has been placed above the client's bed to assist with getting out of bed.
B)The house has one bathroom with a traditional bathtub.
C)Skid-proof strips have been placed on the area rugs in the house.
D)Most of the houseplants appear to have dying foliage.

Question 12

The nurse is caring for a female client who has just completed taking a shower. The nurse notes that she is using her own hair dryer to dry her hair. Which is the nurse's best statement to the client concerning this possible safety issue?

A)"I noticed you are using your own hair dryer. We don't allow that."
B)"Before you start drying your hair, let me see if our maintenance department can come up and check it for safety."
C)"We usually don't allow clients to use their own electrical products from home but if I don't see you use it, then I don't know you have it."
D)"Your hair looks good just the way it is. Please put the hair dryer away for today."

Question 13

The nurse has completed an assessment of an older adult client who lives with her son and his wife. The nurse observed some bruising on the client but no other signs of abuse. Which question by the nurse to the client would be most helpful in determining if abuse is occurring?

A)"Who manages your money?"
B)"How did the bruises I noted on your wrists occur?"
C)"Are you happy with where you live?"
D)"How often do you see the doctor?"

Question 14

The nurse is caring for a client who is disoriented and confused. Which is the safest and least restrictive way to assist this client?

A)Place a wrist restraint on the right arm only.
B)Dim the lights and keep the room as quiet as possible.
C)Put the call light on the client's bed but remove everything else from the client's line of vision.
D)Turn off the lights but turn on the television so the client thinks someone is in the room.

Question 15

The nurse is caring for a client who becomes occasionally confused. When the client has a period of confusion, he attempts to pull out his Foley catheter. When the client is oriented, he likes to do crossword puzzles. After receiving an order for restraints, which would be the best place(s)to place the restraint in this client?

A)Around the client's elbows
B)Around the client's wrists
C)Around the client's fingers (using a mitt restraint)
D)Around the client's torso (using a vest-type restraint)

Question 16

The nurse is developing a safety plan for an older adult client who has just been admitted to the nursing unit. The client has limited hearing and eyesight. His medications include furosemide (Lasix)and a baby aspirin. He still lives alone in his home and is able to do small household chores but his daughter comes over every week to take him grocery shopping. Which information will have an impact on the development of the safety plan? Select all that apply.

A)The client takes furosemide.
B)The client takes aspirin.
C)The client has limited hearing and eyesight.
D)The client lives alone.
E)The client's daughter takes him grocery shopping.

Question 17

The nurse is caring for four clients and knows that which client is at the highest risk for falls?

A)An older adult client who is 2 days postoperative from a hip replacement, uses a walker to ambulate, and requires pain medication every 6 hours
B)An older adult client who had a coronary artery stent placed three days ago
C)An older adult client who is preparing for discharge and requires continued antibiotics
D)An older adult client who was admitted yesterday for dehydration and is confused and sometimes combative

Question 18

The nurse is assessing an older adult client who has come to the emergency department with a possible urinary tract infection. Which would alert the nurse that this client has been abused?

A)The right knee has a large bruise.
B)The underwear smells of urine.
C)There are bilateral contusions above the elbows.
D)There are small lacerations on the forehead.

Question 19

The nurse notices a fire at the end of the hall of a second-floor unit and recognizes that the clients will need to be evacuated out of the hospital. The nurse will use which carrying method to evacuate clients safely out of the hospital?

A)Blanket method
B)Cradle method
C)Back-strap method
D)Two-person swing method

Question 20

The nurse is discussing safety precautions at home with the parents of an 8-year-old child diagnosed with a seizure disorder. Which play activity would the nurse recommend to this family?

A)Sitting quietly reading a book
B)Swimming at the beach
C)Riding a bicycle
D)Participating on a robotic team