Deck 30: Safety

Question 1

The patient keeps more than 30 cats in the home and is unable to adequately care for them.Which is the priority nursing diagnosis for this patient?

A) Disturbed sensory perception related to inability to smell cat feces
B) Caregiver role strain related to inability to adequately care for 30 cats
C) Impaired home maintenance related to unhygienic,unclean surroundings
D) Risk for situational low self-esteem related to neglected home environment

Answer 1

Impaired home maintenance related to unhygienic,unclean surroundings

Question 2

The patient's home is filled with papers and trash that has accumulated over the last 20 years.Which is the priority nursing diagnosis for the patient?

A) Unilateral neglect related to inadequate support systems
B) Ineffective coping related to hoarding behaviors
C) Risk for falls related to cluttered walkways and untidy environment
D) Readiness for enhanced comfort related to desire for nicer surroundings

Answer 2

Risk for falls related to cluttered walkways and untidy environment

Question 3

Which is the role of the nurse regarding a malfunctioning IV pump?

A) Contact the IV pump manufacturer.
B) Initiate a work order on the IV pump.
C) Tag the IV pump and remove it from the area.
D) Clean the fixed IV pump and return it to the floor.

Answer 3

Tag the IV pump and remove it from the area.

Question 4

Which assessment finding leads the nurse to add risk for poisoning to the patient's care plan?

A) The patient takes alprazolam 0.25 mg every 8 hours.
B) The patient rinses with a fluoride mouthwash after brushing the teeth.
C) The patient takes acetaminophen 1000 mg every 4 hours around the clock.
D) The patient frequently uses an alcohol-based sanitizer for hand hygiene.

Question 5

Which assessment finding indicates that the patient is at risk for developing hypothermia?

A) The patient is disoriented due to senile dementia.
B) The patient is 5-foot 6-inch tall with a BMI of 35.
C) The patient has a history of congestive heart failure.
D) The patient takes three different antihypertensive medications.

Question 6

The nurse is applying soft wrist restraints to the patient.Where will the restraints be tied to the patient's bed?

A) Side rails
B) Bedframe
C) Footboard
D) Headboard

Question 7

Into which seating position will the nurse teach a family to place their 18-month-old toddler in the family car?

A) Front seat facing backward
B) Rear seat facing backward
C) Front seat facing forward
D) Rear seat facing forward

Question 8

Which is an example of a procedure-inherent accident?

A) The patient suffered a burn due to a malfunctioning heating pad.
B) The patient suffered a tongue laceration during a grand mal seizure.
C) The nurse suffered a back injury when repositioning a heavy patient in bed.
D) The physician suffered a broken wrist after it was caught in the elevator door.

Question 9

The nurse is caring for a patient who has ongoing headaches,nausea,dizziness,and fatigue since the weather turned cold and snowy.Which assessment question is most important to ask the patient?

A) "Has your furnace been inspected lately?"
B) "Have you checked your roof for any leaks?"
C) "When was the last time your house was painted?"
D) "When did you change your smoke detector batteries?"

Question 10

When a parent asks how to seat a 6-year-old child in the family car,how will the nurse respond?

A) In the rear seat with lap and shoulder seat belts
B) In the front seat with lap and shoulder seat belts
C) In the rear seat with a belt-positioning booster seat
D) In the front seat with a belt-positioning booster seat

Question 11

Which is the highest priority nursing diagnosis for a college student who is living away from home for the first time?

A) Sleep deprivation related to noisy dormitory environment
B) Risk-prone health behavior related to weekend binge drinking
C) Relocation stress syndrome related to moving away from home
D) Risk for loneliness related to being away from family and old friends

Question 12

Which assessment finding leads the nurse to add ineffective protection to the patient's care plan?

A) The patient follows a gluten-free,low-sodium,antiinflammatory diet.
B) The patient has not received immunizations against influenza or pneumonia.
C) The patient recently divorced after being in an unhappy marriage for 4 years.
D) The patient takes levothyroxine daily to treat hypothyroid disease.

Question 13

Which is the highest priority intervention for a patient with diabetic neuropathy who has lost sensation in both feet?

A) Encourage the patient to participate in tai chi exercises to promote balance.
B) Instruct the patient to wear a medical alert bracelet that identifies risk for falls.
C) Evaluate the patient's blood pressure for orthostatic hypotension.
D) Teach the patient to wear low-heeled,comfortable,supportive footwear at all times.

Question 14

Which intrinsic assessment finding could lead a patient to fall?

A) The patient has orthostatic hypotension and faints when standing too quickly.
B) The patient's room is located at the end of the hall far from the nursing station.
C) The patient's roommate sometimes spills the contents of a urinal on the floor.
D) The patient's room is crowed with walkers,wheelchairs,and bedside commodes.

Question 15

A small amount of mercury was spilled on the floor after an old sphygmomanometer was broken.What is the priority action of the nurse?

A) Disinfect the area with a solution of chlorine bleach.
B) Contact the housekeeping staff to mop up the liquid.
C) Wipe up the liquid using paper towels and nitrile gloves.
D) Consult the agency's materials safety data sheets (MSDS).

Question 16

Which assessment finding indicates that the patient is at higher risk for a motor vehicle accident?

A) The patient is 18 years of age.
B) The patient drives a bright blue sedan.
C) The patient is the youngest of six children.
D) The patient has a history of juvenile arthritis.

Question 17

The patient is aggressively attempting to pull out IV lines and hurt staff members.Which is the first action of the nurse?

A) Conduct a thorough mental status assessment.
B) Contact the health care provider to obtain an order for restraints.
C) Place the patient in soft restraints to prevent injury.
D) Document the patient's actions in the medical record.

Question 18

A patient's spouse smokes cigarettes in the kitchen while the patient uses supplemental oxygen in the bedroom.Which is the priority nursing diagnosis for this family?

A) Risk for injury related to smoking near supplemental oxygen
B) Risk-prone health behavior related to inability to quit smoking
C) Ineffective health maintenance related to continued use of cigarettes
D) Ineffective family therapeutic regimen management related to noncompliance

Question 19

The nurse is caring for a patient who took 60 acetaminophen tablets.Which resource will the nurse contact for treatment guidelines when the patient arrives in the emergency room?

A) American Association of Poison Control Centers
B) Centers for Disease Control and Prevention
C) Agency for Healthcare Research and Quality
D) Institute for Safe Medication Practices

Question 20

The patient lives in an apartment and has difficulty getting on and off of the toilet.Which is the best intervention to protect the patient's safety?

A) Place a bedside commode over the toilet.
B) Screw grab bars into the wall by the toilet.
C) Attach suction cup grab bars to the wall by the toilet.
D) Instruct the patient to lean forward when rising to stand.

Question 21

Which patient care need may be delegated to the nursing assistant?

A) Providing discharge teaching about fall precautions in the home
B) Responding to the patient's bed alarm as the patient attempts to get up
C) Performing a mental status assessment to check for confusion or delirium
D) Obtaining a consult for physical therapy for strengthening/balance exercises

Question 22

A patient smokes in the hospital bathroom and starts a fire.Which is the nurse's first response?

A) Remove the patient to a safe area.
B) Close the door to contain the fire.
C) Call the operator to activate the fire alarm.
D) Utilize a fire extinguisher to put out the fire.

Question 23

The wrong type of medication was administered to the patient.Which type of error is this?

A) Exposure-related accident
B) Procedure-related accident
C) Equipment-related accident
D) Organization-related accident

Question 24

Which is the appropriate disposal method for used insulin syringes at home?

A) Engage the safety cap over the needle and place it in the recycle bin.
B) Remove the needle from the syringe and then flush it down the toilet.
C) Place the used syringes in a sharps container that is mailed back for destruction.
D) Place the used needles in a plastic can that is placed in the center of the trash bin.

Question 25

The patient's electricity has been shut off after failure to pay the utility bills.Which actions by the patient pose health hazards?

A) The gas oven is used to warm the kitchen.
B) Extra layers of warm clothing are worn.
C) Food is smelled to determine if it is edible.
D) Dry ice is used to keep milk and eggs cold.
E) Lit taper candles are placed around the house.

Question 26

A patient has just undergone an abdominal aortic aneurysm repair.The patient is pulling at the Foley catheter,nasogastric tube,central line,and abdominal dressing,and a wrist restraint is applied after an order is received.Later,the patient reports tingling and numbness in the fingers and hand.Which actions should the nurse take?

A) Stay with the patient.
B) Medicate the patient for pain.
C) Notify the health care provider.
D) Remove the restraint immediately.
E) Tell the patient to relax and it will feel better shortly.

Question 27

Which nursing diagnosis is the highest priority for a family with small children?

A) Risk for suffocation related to unattended swimming pool in back yard
B) Risk for caregiver role strain related to four children under 6 years of age
C) Readiness for enhanced immunization status related to request for medical records
D) Readiness for enhanced parenting related to attachment between family members

Question 28

Which nursing diagnosis is the highest priority for a sexually active adolescent?

A) Risk for infection related to participation in unprotected sexual activity
B) Disturbed body image related to depersonalization and fear of rejection
C) Spiritual distress related to inability to integrate sexuality with church teaching
D) Risk for compromised human dignity related to loss of respect from peer group

Question 29

Which is the appropriate intervention for a patient with the nursing diagnosis wandering related to disorientation,memory loss,and urge incontinence?

A) Raise three of the four side rails on the patient's bed.
B) Assign the patient to a room close to the nursing station.
C) Remind the patient to always ask for help before getting up.
D) Place a bed alarm to notify staff when the patient is getting up.