Deck 27: Patient Safety and Quality

Question 1

The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?

A) 60° to 64° F
B) 65° to 75° F
C) 15° to 17° C
D) 25° to 28° C

Answer 1

65° to 75° F

Question 2

When making rounds the nurse observes a purple wristband on a patient's wrist. How will the nurse interpret this finding?

A) The patient is allergic to certain medications or foods.
B) The patient has do not resuscitate preferences.
C) The patient has a high risk for falls.
D) The patient is at risk for seizures.

Answer 2

The patient has do not resuscitate preferences.

Question 3

The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working?

A) The patient continues to get up from the chair at the nurses' station.
B) The patient gets restless when the sitter leaves for lunch.
C) The patient folds three washcloths over and over.
D) The patient apologizes for being "such a bother."

Answer 3

The patient folds three washcloths over and over.

Question 4

A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?

A) Respiratory rate
B) Temperature
C) Apical pulse
D) Blood pressure

Question 5

A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?

A) "Every December is the time to change batteries on the carbon monoxide detector."
B) "I will schedule an appointment with a chimney inspector next week."
C) "If I feel dizzy when using the heater, I need to have it inspected."
D) "When it is cold outside in the winter, I will use a nonvented furnace."

Question 6

The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next?

A) Do nothing, no harm has occurred.
B) Notify the health care provider.
C) Complete an incident report.
D) Assess the patient.

Question 7

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint?

A) The patient refuses to call for help to go to the bathroom.
B) The patient continues to remove the nasogastric tube.
C) The patient gets confused regarding the time at night.
D) The patient does not sleep and continues to ask for items.

Question 8

The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?

A) Increased aggressiveness and blood spots on clothing may indicate substance abuse.
B) Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing.
C) Adolescents need information about the effects of uncoordination on accidents.
D) Adolescents need to be reminded to use seat belts primarily on long trips.

Question 9

The nurse is discussing about threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?

A) "Smoking even at parties is not good for my body."
B) "Our campus is safe; we leave our dorms unlocked all the time."
C) "As long as I have only two drinks, I can still be the designated driver."
D) "I am young, so I can work nights and go to school with 2 hours' sleep."

Question 10

The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing?

A) Young infant
B) Toddler
C) Preschooler
D) Adolescent

Question 11

The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?

A) "Are you able to hear the tornado sirens in your area?"
B) "Are you able to read your favorite book?"
C) "Are you able to taste spices like before?"
D) "Are you able to open a jar of pickles?"

Question 12

A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session?

A) Proper fit of a bicycle helmet
B) Proper fit of soccer shin guards
C) Proper fit of swimming goggles
D) Proper fit of baseball sliding shorts

Question 13

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient's health care needs?

A) The electricity was turned off 3 days ago.
B) The water comes from the county water supply.
C) A son and family recently moved into the home.
D) This home is not furnished with a microwave oven.

Question 14

A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?

A) Wash hands
B) Wash wound
C) Wear gloves
D) Wear eye protection

Question 15

A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?

A) 55 years old
B) 20/20 vision
C) Urinary continence
D) Orthostatic hypotension

Question 16

Which activity will cause the nurse to monitor for equipment-related accidents?

A) Uses a patient-controlled analgesic pump
B) Uses a computer-based documentation record
C) Uses a measuring device that measures urine
D) Uses a manual medication-dispensing device

Question 17

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take?

A) Assess the patient.
B) Gather restraint supplies.
C) Try alternatives to restraint.
D) Call the health care provider for a restraint order.

Question 18

The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event?

A) No blood incompatibility occurs with a blood transfusion.
B) A surgical sponge is left in the patient's incision.
C) Pulmonary embolism after lung surgery
D) Stage II pressure ulcer

Question 19

The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring?

A) Tile floors, cold food, scratchy linen, and noisy alarms
B) Dirty floors, hallways blocked, medication room locked, and alarms set
C) Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach
D) Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

Question 20

A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?

A) Check on the patient once a shift.
B) Encourage visitors in the early evening.
C) Place all four side rails in the "up" position.
D) Keep the patient on fall risk until discharge.

Question 21

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?

A) Impaired home maintenance
B) Deficient knowledge
C) Risk for poisoning
D) Risk for injury

Question 22

The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.)

A) Water outdoor plants with a nozzle and hose.
B) Walk to the mailbox in the summer.
C) Encourage yearly eye examinations.
D) Use bathtubs without safety strips.
E) Keep pathways clutter free.

Question 23

A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?

A) Remove the restraint.
B) Place a blanket over the feet.
C) Immediately do a complete head-to-toe neurologic assessment.
D) Take the patient's blood pressure, pulse, temperature, and respiratory rate.

Question 24

During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?

A) The patient is oriented.
B) The patient takes a hypnotic.
C) The patient walks 2 miles a day.
D) The patient recently became widowed.

Question 25

A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?

A) Identifies patient with one identifier before transporting to x-ray department
B) Initiates an intravenous (IV) catheter using clean technique on the first try
C) Uses medication bar coding when administering medications
D) Obtains vital signs to place on a surgical patient's chart

Question 26

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.)

A) Smoking in bed helps me relax and fall asleep.
B) We never leave candles burning when we are gone.
C) We use the same space heater my grandparents used.
D) We use the RACE method when using the fire extinguisher.
E) There is a fire extinguisher in the kitchen and garage workshop.

Question 27

An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient?

A) Positions patient's buttocks close to the front of wheelchair seat
B) Backs wheelchair into elevator, leading with large rear wheels first
C) Places locked wheelchair on same side of bed as patient's weaker side
D) Unlocks wheelchair for easy maneuverability when patient is transferring

Question 28

A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?

A) Determining the need for restraints
B) Assessing the patient's orientation
C) Obtaining an order for a restraint
D) Applying the restraint

Question 29

The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?

A) "The number for poison control is 800-222-1222."
B) "Never induce vomiting if my grandchild drinks bleach."
C) "I should call 911 if my grandchild loses consciousness."
D) "If my grandchild eats a plant, I should provide syrup of ipecac."

Question 30

A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident?

A) Pathogenic asepsis
B) Medical asepsis
C) Surgical asepsis
D) Clean asepsis

Question 31

A home health nurse is assessing a family's home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up?

A) Plastic grocery bags are neatly stored under the counter.
B) Electric outlets are covered in all rooms.
C) No bumper pads are in the crib.
D) Crib slats are 5 cm apart.

Question 32

Which patient will the nurse see first?

A) A 56-year-old patient with oxygen with a lighter on the bedside table
B) A 56-year-old patient with oxygen using an electric razor for grooming
C) A 1-month-old infant looking at a shiny, round battery just out of arm's reach
D) A 1-month-old infant with a pacifier that has no string around the baby's neck

Question 33

The nurse is performing the "Timed Get Up and Go (TUG)" assessment. Which actions will the nurse take? (Select all that apply.)

A) Ranks a patient as high risk for falls after patients takes 18 seconds to complete
B) Teaches patient to rise from straight back chair using arms for support
C) Instructs the patient to walk 10 feet as quickly and safely as possible
D) Observes for unsteadiness in patient's gait
E) Begins counting after the instructions
F) Allows the patient a practice trial

Question 34

A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session?

A) Run wires under the carpet.
B) Disconnect items before cleaning.
C) Grasp the cord when unplugging items.
D) Use masking tape to secure cords to the floor.

Question 35

A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.)

A) Health care provider orders restraints prn (as needed).
B) Health care provider writes the type and location of the restraint.
C) Health care provider renews orders for restraints every 24 hours.
D) Health care provider performs a face-to-face assessment prior to the order.
E) Health care provider specifies the duration and circumstances under which the restraint will be used.

Question 36

The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action?

A) The patient removes the armband to bathe.
B) The patient wears the red nonslip footwear.
C) The patient insists on taking a "water" pill in the evening.
D) The patient who is allergic to penicillin asks the name of a new medicine.

Question 37

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one?
1) Pull the alarm.
2) Remove the patient.
3) Use the fire extinguisher.
4) Close doors and windows.

A) 2, 1, 4, 3
B) 1, 2, 4, 3
C) 1, 2, 3, 4
D) 2, 1, 3, 4

Question 38

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care?

A) Risk for falls
B) Deficient knowledge
C) Risk for suffocation
D) Impaired physical mobility

Question 39

A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?

A) Risk for injury: Check on patient every 15 minutes.
B) Risk for suffocation: Place "Oxygen in Use" sign on door.
C) Disturbed body image: Encourage patient to express concerns about body.
D) Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.

Question 40

The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?

A) Monitor for specific symptoms.
B) Manage all patients using standard precautions.
C) Transport patients quickly and efficiently through the elevators.
D) Prepare for post-traumatic stress associated with this bioterrorism attack.

Question 41

The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.)

A) Close all doors.
B) Note evacuation routes.
C) Note oxygen shut-offs.
D) Move bedridden patients in their bed.
E) Wait until the fire department arrives to act.
F) Use type B fire extinguishers for electrical fires.

Question 42

The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.)

A) One family member has gone to lunch.
B) Patient is placed in bilateral wrist restraints at 0815.
C) Bilateral radial pulses present, 2+, hands warm to touch
D) Straps with quick-release buckle attached to bed side rails
E) Attempts to distract the patient with television are unsuccessful.
F) Released from restraints, active range-of-motion exercises completed

Question 43

The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family? (Select all that apply.)

A) Demonstrate how to restrain the patient in the event of a seizure.
B) Instruct the family to move the patient to a bed during a seizure.
C) Teach the family how to insert a tongue depressor during the seizure.
D) Discuss with the family steps to take if the seizure does not discontinue.
E) Instruct the family to reorient and reassure the patient after consciousness is regained.

Question 44

The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.)

A) Where did you fall?
B) What time did the fall occur?
C) What were you doing when you fell?
D) What types of injuries occurred after the fall?
E) Did you obtain an electronic safety alert device after the fall?
F) What are your medical problems that may have caused the fall?