Chapter 37: Client Safety Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. The nurse has investigated safety hazards and recognizes that which one of the following statements is accurate regarding safety needs?

a.

Bacterial contamination of foods is uncontrollable.

b.

Fire is the greatest cause of unintentional death.

c.

Carbon dioxide levels should be monitored in home settings.

d.

Temperature extremes seldom affect the safety of clients in acute care facilities.

ANS: c

c. Annual inspections of heating systems, chimneys, and appliances should be done in private homes. Carbon monoxide detectors are available but should not be used as a replacement for proper use and maintenance of fuel-burning appliances.

a. Bacterial contamination of foods is controllable. The FDA is a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances.

b. Motor vehicle accidents are the leading cause of unintentional death, not fire.

d. Temperature extremes can affect the safety of clients in acute care facilities, especially older adults.

REF: Text Reference: p. 961

2. An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimers disease. In using a Fall Assessment tool, the nurse knows that the greatest indicator of risk is:

a.

Confusion

b.

Impaired judgment

c.

Sensory deficits

d.

History of falls

ANS: d

d. According to the Fall Assessment tool, the greatest indicator of risk is a history of falls.

a. According to the Fall Assessment tool, the second leading risk factor for falls is confusion.

b. According to the Fall Assessment tool, impaired judgment is the fourth leading risk factor for falls.

c. According to the Fall Assessment tool, sensory deficit is the fifth leading risk factor for falls.

REF: Text Reference: p. 969

3. An inservice program is being offered in the hospital on bioterrorism and the response of the health care agency. During the program, the mitigation phase is described. The nurse is informed that this phase includes:

a.

Determination of hazard vulnerability and the impact of the emergency situation

b.

Steps taken to manage the effects of the event and an inventory of available resources

c.

Steps taken by staff to perform triage for victims

d.

Restoration of essential services

ANS: a

a. The mitigation phase consists of the assessment process to determine hazard vulnerability for the hospitals service area. This includes an identification of the kinds of emergency situations that are most likely to occur and their probable impact.

b. During the preparedness phase, steps are taken to manage the effects of the event, and an inventory of available resources is taken.

c. During the response phase, steps are taken by staff to triage victims.

d. During the recovery phase, steps are taken to restore essential services.

REF: Text Reference: p. 996

4. An inservice program is being offered in the hospital on bioterrorism and the response of the health care agency. An important aspect of the program is the recognition of the signs and symptoms of bacterial and viral infections. A practice drill is held, and the nurse recognizes that the clients admitted with possible anthrax will demonstrate:

a.

Abdominal cramping, diarrhea, drooping eyelids, jaw clench, and difficulty swallowing

b.

Flu-like symptoms, gastrointestinal distress, and papular lesions

c.

Fever, cough, chest pain, and hemoptysis

d.

Vesicular skin lesions on the face and extremities

ANS: b

b. Clinical features of anthrax include flu-like symptoms, gastrointestinal distress, and popular lesions.

a. Abdominal cramping, diarrhea, drooping eyelids, jaw clench, and difficulty swallowing are clinical features of botulism.

c. Fever, cough, chest pain, and hemoptysis are characteristic of plague.

d. Vesicular skin lesions on the face and extremities are seen with smallpox.

REF: Text Reference: p. 970

5. A 1-year-old child is scheduled to receive an intravenous (IV) line. The most appropriate type of restraint to use for this client to prevent removal of the IV line would be a(n):

a.

Wrist restraint

b.

Jacket restraint

c.

Elbow restraint

d.

Mummy restraint

ANS: d

d. A mummy restraint is used in the short-term for a small child or infant for examination or treatment involving the head and neck. This would be the most appropriate type of restraint to use for a 1-year-old who is going to receive an IV line.

a. The wrist restraint maintains immobility of an extremity to prevent the client from removing a therapeutic device, such as an IV tube. It would not be the best choice for starting an IV on a 1-year-old.

b. The jacket restraint is often used to prevent a client from getting up and falling. It is not the best choice for starting an IV line.

c. An elbow restraint is commonly used with infants and children to prevent elbow flexion, such as after an IV line is in place.

REF: Text Reference: p. 986

6. A 79-year-old resident in a long-term care facility is known to wander at night and has fallen in the past. Which of the following is the most appropriate nursing intervention?

a.

An abdominal restraint should be placed on the client during sleeping hours

b.

The client should be checked frequently during the night

c.

A radio should be left playing at the bedside to assist in reality orientation

d.

The client should be placed in a room away from the activity of the nursing station

ANS: b

b. Alternatives to restraints should be attempted first. (A physicians order is required for restraints to be applied). The most appropriate intervention is to check on the client frequently.

a. Alternatives to restraints should be attempted first.

c. A radio may help orient a client to reality. However, the most appropriate intervention for the client who wanders is to check on the client frequently.

d. Clients who wander should be assigned to rooms near the nurses station and checked on frequently.

REF: Text Reference: p. 982, Text Reference: p. 983

7. The workmen cause an electrical fire when installing a new piece of equipment in the intensive care unit. A client is on a ventilator in the next room. The first action the nurse should take is to:

a.

Pull the fire alarm

b.

Attempt to extinguish the fire

c.

Call the physician to obtain orders to take the client off the ventilator

d.

Use an Ambu bag and remove the client from the area

ANS: d

d. If there is a fire and the client is on life support, the nurse should maintain the clients respiratory status manually with an Ambu-bag and move the client away from the fire.

a. The first action of the nurse is not to pull the fire alarm. The workmen could do that.

b. The workman can attempt to extinguish the fire. The nurse should attend to the client who is closest to the fire in the next room.

c. The nurse should not call the doctor to obtain orders to take the client off the ventilator, as this will take valuable time. The client must be moved away from the fire and the source of oxygen must be discontinued, as it is combustible. The client will need to be manually resuscitated with an Ambu-bag.

REF: Text Reference: p. 991

8. In a nursing home an elderly client drops his burning cigarette in a trash can and starts a fire. The most appropriate type of fire extinguisher for the nurse to use is the:

a.

Type A

b.

Type B

c.

Type C

d.

Type D

ANS: a

a. Type A fire extinguishers are used for ordinary combustibles such as wood, cloth, paper, and plastic. A trash can fire would require a type A fire extinguisher.

b. Type B fire extinguishers are used for flammable liquids such as gasoline, grease, paint, and anesthetic gas.

c. Type C fire extinguishers are used for electrical equipment.

d. There is no Type D fire extinguisher.

REF: Text Reference: p. 991

9. A visiting nurse completes an assessment of the ambulatory client in the home and determines the nursing diagnosis of Risk for injury related to decreased vision. Based on this assessment, the client will benefit the most from:

a.

Installing fluorescent lighting throughout the house

b.

Becoming oriented to the position of the furniture and stairways

c.

Maintaining complete bed rest in a hospital bed with side rails

d.

Applying physical restraints

ANS: b

b. Orienting the client to the position of furniture in the room and stairways is the best intervention to help prevent falls for the client with decreased vision.

a. Attempts should be made to reduce glare. Light bulbs that are 60 watts or less may be increased to 75 watts to help improve visibility. The best intervention to prevent falls is first to orient the client to the surroundings.

c. Maintaining complete bed rest is not the best option. Complete bed rest can cause other health problems because of a lack of mobility.

d. The client should not be restrained for poor vision. Attempts should be made to help compensate for the decreased vision to prevent falls.

REF: Text Reference: p. 979

10. Which one of the following statements by the parent of a child indicates that further teaching by the nurse is required?

a.

Now that my child is 2 years old, I can let her sit in the front seat of the car with me.

b.

I make sure that my child wears a helmet when he rides his bicycle.

c.

I have spoken to my child about safe sex practices.

d.

My child is taking swimming classes at the community center.

ANS: a

a. This statement indicates that further teaching is required. Children weighing less than 80 pounds or younger than 8 years should always be in an age/weight-appropriate car seat that has been installed according to manufacturers directions. In cars with a passenger air bag, children younger than 12 should be in the back seat.

b. This is an appropriate safety measure to reduce injuries from falling off a bike or being hit by a car.

c. This is an important safety measure, as many adolescents begin sexual relationships.

d. This is an appropriate safety measure that may someday save a childs life.

REF: Text Reference: p. 977

11. The nurse assesses that the client may need a restraint and recognizes that:

a.

An order for a restraint may be implemented indefinitely until it is no longer required by the client.

b.

Restraints may be ordered on an as-needed basis.

c.

No order or consent is necessary for restraints in long-term care facilities.

d.

Restraints are to be periodically removed to have the client re-evaluated.

ANS: d

d. Restraints must be periodically removed, and the nurse must assess the client to determine if the restraints continue to be needed.

a. This is not a true statement. A physicians order for restraints must have a limited time frame. If the orders are renewed, it should be done so within a specified time frame according to the agencys policy.

b. Restraints are not to be ordered prn (as needed).

c. The use of restraints must be part of the clients medical treatment. An order or consent is necessary for restraints in long-term care facilities.

REF: Text Reference: p. 981

12. On entering the clients room, the nurse sees a fire burning in the trash can next to the bed. The nurse removes the client and calls in the fire. The next action of the nurse is to:

a.

Extinguish the fire

b.

Remove all of the other clients from the unit

c.

Close all the doors of client rooms

d.

Move the trash can into the bathroom

ANS: c

c. The next action the nurse should take is to confine the fire by closing doors and windows and turning off oxygen and electrical equipment.

a. The nurse should extinguish the fire by using an extinguisher after closing the doors of the client rooms.

b. After activating the alarm, the nurse should close all the doors, not remove all of the other clients from the unit.

d. This would not be an appropriate action, as the nurse could get burned in attempting to move the trash can.

REF: Text Reference: p. 991

13. A mother of a young child enters the kitchen and finds the child on the floor. A bottle of cleanser is next to the child, and particles of the substance are around the childs mouth. The parents first action should be to:

a.

Call the Poison Control unit

b.

Provide ipecac syrup

c.

Check the childs airway and breathing

d.

Remove the particles of cleanser from the mouth

ANS: c

c. The first action is to assess for airway patency, breathing, and circulation.

a. After checking the childs airway, breathing, and circulation, the parent should remove any particles of cleanser from the mouth. The parent should identify the type and amount of substance ingested and then call the Poison Control unit.

b. The parent should administer ipecac syrup only if instructed to induce vomiting by the Poison Control unit. Administering ipecac is not the parents first action.

d. Removing the particles of cleanser is not the parents first action. The parent may do so after assessing the childs airway, breathing, and circulation.

REF: Text Reference: p. 993

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