Question 1

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

Accepted Answer

The priority nursing diagnosis is risk for injury.This patient could cause harm to himself by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out.Before restraining a patient,it is important to implement and exhaust alternatives to restraint.Alternatives can include distraction and providing companionship or supervision.Patients may be moved to a location closer to the nurses' station; trained sitters or family members may be involved.Nurses need to ensure that patients are provided adequate food,liquid,toileting,and relief from pain.If these and other alternatives fail,this individual may need restraints; in this case,an order would need to be obtained for the restraint.This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints; however,the nursing diagnosis of highest priority is risk for injury.This scenario does not indicate that the patient has a disturbed body image or that the patient's caregiver is strained.

Question 2

The older patient presents to the emergency department after stepping in front of a car at a crosswalk.After the patient has been triaged,the nurse interviews the patient.Which of the following comments would require follow-up by the nurse?

Accepted Answer

The patient did not see or hear the car coming.As patients age,sensory impairment can increase the risk for injury.This statement by the patient would require follow-up by the nurse.The patient needs hearing and eye examinations.Exercise is important at every stage of development.The patient seemed to comprehend how to cross an intersection correctly and was able to determine the speed of the car.

Question 3

The emergency department has been notified of a potential bioterrorist attack.The nurse assigned to the department realizes that the most important task for safety in this situation is to

Accepted Answer

It is essential to determine the agent and manage all patients who are symptomatic with the suspected or confirmed bioterrorism-related illness using Standard Precautions.For certain diseases,additional precautions may be necessary.Clustering patients may be helpful with staffing and,depending on the illness,may decrease the spread.All nurses every day should carry out their roles quickly and efficiently.Psychosocial concerns are important but are not the first priority at this moment.

Question 4

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 of the following nursing diagnoses will the nurse add to the patient's plan of care?

Accepted Answer

The patient needs to understand the purpose of the compression devices and that proper application is needed for them to be effective.The patient has a knowledge need and requires instruction regarding the device and its purpose and procedure.The nurse will intervene by teaching the patient about the sequential compression device and instructing the patient to call for assistance when getting up to go to the bathroom in the future,so that the nurse may assist with removal and proper reapplication.No data support a risk for poisoning,imbalanced body temperature,or suffocation.

Question 5

An elderly patient presents to the hospital with a history of falls,confusion,and stroke.The nurse determines that the patient is at high risk for falls.Which of the following interventions is most appropriate for the nurse to take?

Accepted Answer

Locking the bed and wheelchairs when transferring will help to prevent these pieces of equipment from moving during transfer and will assist in the prevention of falls.Patients are not automatically placed in restraints.The restraint process consists of many steps,including thorough assessment and exhausting of alternatives.All mats and rugs should be secured to help prevent falls.Silencing alarms upon the request of family is not appropriate and could contribute to an unsafe environment.

Question 6

The nurse has placed a patient on high-risk alert for falls.Which of the following observations by the nurse would indicate that the patient has an understanding of this alert?

Accepted Answer

Red nonslip footwear helps to grip the floor and decreases the chance of falling.The communication armband should stay in place and should not be removed,so that all members of the interdisciplinary team have the information about the high risk for falls.Call lights should be kept within reach of the patient.Taking diuretics early in the day assists with decreasing the number of bathroom trips at night-the time when falls are most frequent.

Question 7

A nurse is caring for an adult patient who has had a minor motor vehicle accident.The health history reveals that the patient is currently in the process of obtaining a divorce.Which of the following actions should the nurse take?

Accepted Answer

Agreeing and making time for conversation,using active listening skills and therapeutic touch,teaching stress reduction strategies,and informing the patient of the risk to health associated with stress are interventions that are within the nurse's scope of practice.Agreeing to witness a telephone conversation could draw the nurse into divorce proceedings when the focus should be on the patient and his health.Referring the patient to the nurse's church counselor without a specific request from the patient may not take into consideration cultural care and could be considered unprofessional.If the patient requested a marriage counselor,a better solution would be to provide a referral to social services that may include a list of possible counselors from which the patient could choose.

Question 8

The nurse has been called to a hospital room where a patient is using a hair dryer from home.The patient has received an electrical shock from the dryer.The patient is unconscious and is not breathing.What is the best next step?

Accepted Answer

In this scenario,the patient is in a hospital setting,and it has been determined that the patient is not conscious and is not breathing.The next step is to check the pulse.An electrical shock can interfere with the heart's normal electrical impulses and can cause arrhythmias.Checking the pulse helps to determine the need for cardiopulmonary resuscitation (CPR)and defibrillation.

Question 9

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 of the following should the patient avoid?

Accepted Answer

Unsecured rugs,using a hose to water plants,missing yearly eye examinations,and using tubs without safety strips are all items the patient should avoid to help in the prevention of falls in the home.Exercise is beneficial and increases strength,which helps with the prevention of falls.It is important that the home is well lit,so encourage the purchase of bulbs with strength of 60 watts or higher for the home.

Question 10

The nurse is instructing the student nurse regarding discharge teaching and medications.Which response by the student would indicate that learning has occurred?

Accepted Answer

Zyprexa and Zyrtec are sound-alike,look-alike medications.Zyprexa is an antipsychotic and Zyrtec an antihistamine; these agents treat two different conditions.Bringing the differences and similarities in spelling and sound to the attention of the patient is important for patient safety.Medications are not distributed by the hospital,and medications do not need to be administered at the same time each day.

Question 11

During the admission assessment,the nurse assesses the patient for fall risk.Which of the following has the greatest potential to increase the patient's risk for falls?

Accepted Answer

Benadryl (diphenhydramine)has the potential to cause drowsiness and dizziness as a side effect,thereby increasing the risk for falls.Over 60 is the age typically found on fall assessments that increase the risk for falls.Walking has many benefits,including increasing strength,which would be beneficial in decreasing risk.Becoming widowed would increase stress and may affect concentration but is not the greatest risk.

Question 12

A patient with an intravenous infusion requests a new gown after bathing.Which of the following actions is most appropriate?

Accepted Answer

Procedure-related accidents such as contamination of sterile items can occur in the health care setting.Keeping the intravenous tubing intact without breaks in the system is imperative to decrease the risk of infection while changing a patient's gown and satisfying the patient's request.

Question 13

The nurse suspects the possibility of a bioterrorist attack.Which of the following factors is most likely related to this possibility?

Accepted Answer

A rapid increase in patients presenting with a specific symptom,lower rates of symptoms among individuals indoors,and large numbers of fatalities with these symptoms all coming from one location are triggers that lead the nurse to suspect a bioterrorist attack.A shortage of personal protective equipment and an increase in the number of staff calling in sick can occur and does occur at times in the hospital setting and may have nothing to do with bioterrorism.

Question 14

A nurse is in the hallway assisting a patient to ambulate and hears an alarm sound.What is the best next step for the nurse to take?

Accepted Answer

The nurse who heard the alarm has a duty to address it even though she is busy with another patient.Ask someone to check on the alarm.The nurse cannot leave the patient in the hallway to look for the source of the alarm and cause a potentially unsafe situation for this patient,but a patient on the unit may have an urgent need.Someone needs to seek out the source of the alarm and address it.Never ignore an alarm.Alarms are in place to maximize the safety of the patient.Waiting to see if an alarm stops may cause a delay in a possible emergency situation.

Question 15

The patient is confused,is trying to get out of bed,and is pulling at the intravenous infusion tubing.These data would help to support a nursing diagnosis of

Accepted Answer

The patient's behaviors support the nursing diagnosis of risk for injury.The patient is confused,is pulling at the intravenous line,and is trying to climb out of bed.Injury could result if the patient falls out of bed or begins to bleed from a pulled line.Nothing in the scenario indicates that this patient lacks knowledge or is at risk for poisoning.Nothing in the scenario refers to the patient's home maintenance.

Question 16

The nurse is precepting a student nurse and is careful to check with the student all components of the medication process.The nurse explains to the student that most errors occur in

Accepted Answer

Most medication errors occur in the ordering and administering stages of the medication process.

Question 17

The nurse is providing information regarding safety and accidental poisoning to a grandmother who will be taking custody of a 1-year-old grandchild.Which of the following comments would indicate that the grandmother needs further instruction?

Accepted Answer

Syrup of ipecac to induce vomiting after ingestion of a poison has not been proven effective in preventing poisoning.This medication should not be administered to the child.The poison control number is 800-222-1222.After a caustic substance such as bleach has been drunk,do not induce vomiting.This can cause further burning and injury as the medication is eliminated.Loss of consciousness associated with poisoning requires calling 911.

Question 18

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed.Immediately,the nurse assigns a nursing diagnosis of risk for injury with a goal for the patient to be safe.Which of the following actions should the nurse take first?

Accepted Answer

Nurses use the mnemonic RACE to set priorities in case of fire.All of these interventions are necessary,but this patient is in immediate danger with the fire being over his head and should be rescued and removed from the situation.

Question 19

The patient presents to the clinic with a family member.The family member states that the patient has been wandering around the house and mumbling.What is the first assessment the nurse should do?

Accepted Answer

Introduce self and engage the patient by asking her name to assess orientation; ask the patient why she is visiting the clinic today.Continue the assessment with vital signs and a complete workup,including a neurologic assessment.

Question 20

Which of the following concepts are important to utilize when evaluating orders for restraints?

Accepted Answer

Physicians are responsible for writing restraint orders and conducting face-to-face evaluations,as well as for putting time limits,specifying when to remove,and time dating and signing orders.Behaviors that necessitate the use of restraint not only are part of the nursing documentation but are to be included as part of the order for restraint.The physician's formatting is not a consideration for evaluating restraint orders.Formatting of restraint orders typically follows state rules and regulations,as well as regulatory agency standards.

Quiz 27: Patient Safety