Chapter 38: Client Safety Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

MULTIPLE CHOICE

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

1.

Bacterial contamination of foods is uncontrollable.

2.

Fire is the greatest cause of unintentional death.

3.

Carbon dioxide levels should be monitored in home settings.

4.

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

ANS: 3

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. 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. Motor vehicle accidents are the leading cause of unintentional death, not fire. Temperature extremes can affect the safety of clients in acute care facilities, especially the elderly.

PTS: 1 DIF: A REF: 812 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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

1.

Confusion

2.

Impaired judgment

3.

Sensory deficits

4.

History of falls

ANS: 4

According to the falls assessment tool, the greatest indicator of risk is a history of falls. According to the falls assessment tool, the second leading risk factor for falls is confusion. According to the falls assessment tool, impaired judgment is the fourth leading risk factor for falls. According to the falls assessment tool, sensory deficit is the fifth leading risk factor for falls.

PTS: 1 DIF: A REF: 817 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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:

1.

Determination of hazard vulnerability and the impact of the emergency situation

2.

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

3.

Steps taken by staff to triage victims

4.

Restoration of essential services

ANS: 1

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. During the preparedness phase, steps are taken to manage the effects of the event, and an inventory of available resources is taken. During the response phase, steps are taken by staff to triage victims. During the recovery phase, steps are taken to restore essential services.

PTS: 1 DIF: A REF: 821 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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:

1.

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

2.

Flulike symptoms, gastrointestinal distress, and papular lesions

3.

Fever, cough, chest pain, and hemoptysis

4.

Vesicular skin lesions on the face and extremities

ANS: 2

Clinical features of anthrax include flulike symptoms, gastrointestinal distress, and papular lesions. Abdominal cramping, diarrhea, drooping eyelids, jaw clench, and difficulty swallowing are clinical features of botulism. Fever, cough, chest pain, and hemoptysis are characteristic of plague. Vesicular skin lesions on the face and extremities are seen with smallpox.

PTS: 1 DIF: A REF: 821 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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

1.

Wrist restraint

2.

Jacket restraint

3.

Elbow restraint

4.

Mummy restraint

ANS: 4

A mummy restraint is used 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 child who is going to receive an IV line. 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 child. 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. An elbow restraint is commonly used with infants and children to prevent elbow flexion, such as after an IV line is in place.

PTS: 1 DIF: A REF: 832 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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?

1.

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

2.

The client should be checked frequently during the night.

3.

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

4.

The client should be placed in a room that is away from the activity of the nurses station.

ANS: 2

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. Alternatives to restraints should be attempted first before an abdominal restraint while sleeping.

A radio may help orientate a client to reality. However, the most appropriate intervention for the client who wanders is to check on the client frequently. Clients who wander should be assigned to rooms near the nurses station and checked on frequently.

PTS: 1 DIF: C REF: 832 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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:

1.

Pull the fire alarm

2.

Attempt to extinguish the fire

3.

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

4.

Use an Ambu-bag and remove the client from the area

ANS: 4

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. The first action of the nurse is not to pull the fire alarm. The workmen could do that. 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. The nurse should not call the doctor to obtain orders to take the client off the ventilator because this will take valuable time. The client needs to be moved away from the fire, and the source of oxygen needs to be discontinued, as it is combustible. The client will need to be manually resuscitated with an Ambu-bag.

PTS: 1 DIF: C REF: 839 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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:

1.

Type A

2.

Type B

3.

Type C

4.

Type D

ANS: 1

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. Type B fire extinguishers are used for flammable liquids such as gasoline, grease, paint, and anesthetic gas. Type C fire extinguishers are used for electrical equipment. There is no type D fire extinguisher.

PTS: 1 DIF: A REF: 840 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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:

1.

Installing fluorescent lighting throughout the house

2.

Becoming oriented to the position of the furniture and stairways

3.

Maintaining complete bed rest in a hospital bed with side rails

4.

Applying physical restraints

ANS: 2

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. 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 to first orient the client to the surroundings. Maintaining complete bed rest is not the best option. Complete bed rest can cause other health problems resulting from a lack of mobility. The client should not be restrained for poor vision. Attempts should be made to help compensate for the decreased vision in order to prevent falls.

PTS: 1 DIF: C REF: 819 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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

1.

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

2.

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

3.

I have spoken to my child about safe sex practices.

4.

My child is taking swimming classes at the community center.

ANS: 1

This statement indicates that further teaching is required. Children weighing less than 80 pounds or who are under 8 years of age 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 under 12 should be in the back seat. Answer 2 is an appropriate safety measure to reduce injuries from falling off a bike or being hit by a car. Answer 3 is an important safety measure because many adolescents begin sexual relationships. Answer 4 is an appropriate safety measure that may someday save a childs life.

PTS: 1 DIF: C REF: 827 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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

1.

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

2.

Restraints may be ordered on an as-needed basis

3.

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

4.

Restraints are to be periodically removed to have the client reevaluated

ANS: 4

Restraints must be periodically removed, and the nurse must assess the client to determine if the restraints continue to be needed. Answer 1 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. Restraints are not to be ordered prn (as needed). 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.

PTS: 1 DIF: A REF: 831 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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:

1.

Extinguish the fire

2.

Remove all of the other clients from the unit

3.

Close all the doors of client rooms

4.

Move the trash can into the bathroom

ANS: 3

The next action the nurse should take is to confine the fire by closing doors and windows and turning off oxygen and electrical equipment. The nurse should extinguish the fire using an extinguisher after closing the doors of the client rooms. After activating the alarm, the nurse should close all the doors, not remove all of the other clients from the unit. Answer 4 would not be an appropriate action because the nurse could get burned in attempting to move the trash can.

PTS: 1 DIF: A REF: 839 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

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

1.

Call the Poison Control unit

2.

Provide ipecac syrup

3.

Check the childs airway and breathing

4.

Remove the particles of cleanser from the mouth

ANS: 3

The first action is to assess for airway patency, breathing, and circulation. 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. The parent should only administer ipecac syrup if instructed to induce vomiting by the Poison Control unit. Administering ipecac is not the parents first action. Removing the particles of cleanser is not the parents first action. The parent may do so after assessing the childs airway, breathing, and circulation.

PTS: 1 DIF: C REF: 840 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

14. Which of the following nursing assessment data are most reflective of hypothermia?

1.

Cyanotic lips, fingers, and toes

2.

Rectal temperature of 35 C (95 F)

3.

Bradycardia of 56 beats per minute

4.

Exposure to outdoor temperatures of <32 F

ANS: 2

Hypothermia occurs when the core body temperature is 35 C (95 F) or below. While the remaining options are not incorrect, they may be due to other factors.

PTS: 1 DIF: A REF: 812 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

15. Which of the following clients who is experiencing the heat of mid-August is at greatest risk for heatstroke or heat exhaustion?

1.

A 65-year-old diagnosed with COPD

2.

A 35-year-old novice marathon runner

3.

A 15-year-old playing in an outdoor tennis tournament

4.

A 9-month-old whose bedroom is cooled with a mechanical fan

ANS: 1

Exposure to extreme heat raises the core body temperature, resulting in heatstroke or heat exhaustion. Chronically ill clients, older adults, and infants are at greatest risk for injury from extreme heat. These clients need to avoid extremely hot, humid environments. While the remaining options reflect a risk, it is not as high as the answer.

PTS: 1 DIF: C REF: 812 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

16. The nurse should recognize which of the following clients as being at greatest risk for an unintentional death?

1.

A 58-year-old who skis regularly

2.

A 44-year-old alcoholic who lives alone

3.

A 72-year-old identified as at high risk for falls

4.

A 34-year-old diagnosed with chronic depression

ANS: 3

Among older adults 65 years and older, falls are the leading cause of unintentional death. While the remaining options reflect clients at risk, the probability is not as great.

PTS: 1 DIF: C REF: 813 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

17. Which of the following nursing interventions has the greatest likelihood of minimizing the risk of injury for a client who frequently gets out of bed at night to go into the bathroom?

1.

Limiting fluid intake after 6 PM

2.

Illuminating the pathway to the bathroom

3.

Toileting the client whenever awake at night

4.

Checking on the client at least hourly during the night

ANS: 2

While checking on the client frequently is not incorrect, night-lights in dark halls, bathrooms, and the rooms of children and older adults help maintain safety by reducing the risk of falls. The remaining options are more directed at controlling urinary output than preventing injury.

PTS: 1 DIF: C REF: 813 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

18. When discussing the prevention of fire-related injuries and deaths, the nurse should place the greatest emphasis on the:

1.

Prevention role smoke detectors play

2.

Dangers of careless smoking habits

3.

Supervision of children around open flames

4.

Importance of readily accessible fire extinguishers

ANS: 2

The leading cause of fire-related death is careless smoking. While the other options reflect risk, they are not as highly prioritized as the answer.

PTS: 1 DIF: C REF: 813 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

19. The nurse recognizes that the leading cause of death for the otherwise healthy 1-year-old is:

1.

Physical abuse

2.

Accidental injury

3.

Contagious diseases

4.

Stranger abduction

ANS: 2

Injuries are the leading cause of death in children older than 1 year of age and cause more deaths and disabilities than do all diseases combined.

PTS: 1 DIF: A REF: 814 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

20. The nurse is preparing a safety-related program for a group of parents of 5- to 14-year-olds. Which of the following topics is most likely to positively impact the leading cause of injury for this age-group?

1.

Keeping them safe while they play sports

2.

Bicycle riding with safety in mind

3.

Safety first when around water

4.

Dont let fire hurt your child

ANS: 2

Children 5 to 14 years of age account for nearly one third of bicyclists killed in traffic accidents. While the remaining options deal with risk factors, the priority relates to bicycle-oriented accidents.

PTS: 1 DIF: C REF: 815 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

21. The nurse recognizes which of the following clients is at greatest risk for an accidental death?

1.

A 60-year-old who is a weekend alcoholic

2.

A 40-year-old who is a professional mountain climber

3.

A 35-year-old who commutes 35 miles to work each morning

4.

A 50-year-old who recently lost his job because of a work-related injury

ANS: 4

The adult experiencing a high level of stress is more likely to have an accident or illness such as headaches, gastrointestinal (GI) disorders, and infections. While the remaining options identify risks, they are not a high as that of the stressed adult.

PTS: 1 DIF: C REF: 815 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

22. A client who is experiencing a generalized clonic-tonic seizure is at greatest risk for injury caused by:

1.

The physical collapse that occurs at the onset of the seizure

2.

Muscle strains that result from the severe muscle jerking during the seizure

3.

The tongue laceration that occurs from jaw clenching during the seizure

4.

Aspiration resulting from the temporary loss of consciousness after the seizure

ANS: 1

During a fall, or as a result of muscle jerking, musculoskeletal injuries can occur. The fall is the most problematic since is occurs in the vast majority of the seizure events.

PTS: 1 DIF: C REF: 817 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

23. Which of the following clients is at greatest risk for injury related to medical diagnoses and conditions?

1.

A history of asthma and alcohol abuse

2.

A history of heart failure and urinary urgency

3.

A history of hypertension and wearing corrective lenses

4.

A history of chronic bronchitis and impaired hearing

ANS: 2

This client is likely using diuretics that increase the frequency of voiding and result in the client having to use toilet facilities more often. Falls often occur with clients who have to get out of bed quickly because of urinary urgency.

PTS: 1 DIF: C REF: 817 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

24. The nurse is conducting an admission interview and assessment on a cognitively impaired, uncooperative client for the risk for injury. Which of the following options will most likely provide the information to confirm the diagnosis?

1.

Base the degree of risk on observable data at the time of the clients current hospital admission.

2.

Closely monitor the clients behavior and habits until risk for injury can be reasonably determined.

3.

Make certain critically sound assumptions are based on the clients developmental stage and current cognitive stasis.

4.

Interview the clients family, friends, and/or caregivers regarding prehospitalization risk factors.

ANS: 4

In many cases family members are important resources in assessing a clients fall risk. Families often are able to report on the clients level of confusion and ability to ambulate.

PTS: 1 DIF: C REF: 818 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

25. A nurse working in an acute care facilitys emergency department should recognize which of the following client reports as being most suspicious of a terrorist attack?

1.

Four deaths resulting from a privately owned airplane crashing into a four-story building

2.

Numerous reports of respiratory distress among older adults who attended an outdoor musical event

3.

15 cases of nausea and vomiting reported over a 2-day period when 4 cases would be within normal for the facility

4.

10 children, all who attended a child-oriented arts and crafts fair, presenting with rashes on their hands and faces

ANS: 3

An unusual increase in the number of people seeking care, especially with fever, respiratory, or gastrointestinal complaints, is a classic indicator of such an event. While the other options present possible indicators, there are other possible reasons for the incidents.

PTS: 1 DIF: C REF: 820 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

26. The nurse is discussing safety issues with the mother of three children. Which of the following statements has the greatest possibility for decreasing the potential for injury among the children?

1.

Where do you see a need for safety improvements in your home?

2.

Keep all toxic liquids capped and stored out of reach of the children.

3.

Installing safety gates at the top and bottom of each set of stairs will help minimize falls.

4.

Take great care to keep the children away from kitchen appliances and tools that can hurt them.

ANS: 1

Clients generally expect to be safe in their homes and health care settings. However, there are times when a clients view of what is safe does not agree with that of the nurse. For this reason, any assessment needs to include the clients understanding of his or her perception of risk factors. The remaining options are directed toward specific safety issues.

PTS: 1 DIF: C REF: 824 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

27. The nurse recognizes that the greatest benefit of engaging the mother of two small children into a discussion about child-proofing her home is that:

1.

The home will be safe for the immediate time being

2.

If an accident occurs, it will likely be minor in nature

3.

She is likely to monitor the house for safety issues in the future

4.

She will serve as a role model regarding safety issues for her children

ANS: 3

The client who is an active participant in reducing threats to safety becomes more alert to potential hazards.

PTS: 1 DIF: C REF: 824 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

28. The nurse and a mother of two small children are discussing child safety issues. Which of the following nursing interventions has the greatest potential for using collaboration to help ensure the childrens safety?

1.

Arranging to teach the children how to react in the case of a fire in the home

2.

Teaching the children to telephone 911 if there is ever an emergency in the home

3.

Helping the mother identify an emergency person for the children to telephone in the case of an emergency

4.

Helping the mother create a list of emergency telephone numbers to be posted next to the homes telephone

ANS: 4

Clients need to learn how to identify and select resources within their community that enhance safety (e.g., neighborhood block homes, local police departments, and neighbors willing to check on a clients well-being).The remaining options deal with individual aspects of a complete plan.

PTS: 1 DIF: C REF: 824 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

29. When preparing a safety workshop for early teens (13 to 15 years old), the nurse recognizes that which of the following active strategy topics has the greatest potential for decreasing injuries in this population by affecting lifestyle changes?

1.

Avoiding the nicotine habit

2.

Keeping immunizations up to date

3.

Eating a well-balanced, low-fat diet

4.

Wearing a seat belt when riding in an automobile

ANS: 4

To promote an individuals health, it is necessary for the individual to be in a safe environment and to practice a lifestyle that minimizes risk of injury. Active strategies are those in which the individual is actively involved through changes in lifestyle (e.g., wearing seat belts or installing outdoor lighting) and participation in wellness programs. Accidents involving automobiles account for the most substantial number of injuries and deaths among this population from among the options provided.

PTS: 1 DIF: C REF: 824 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

30. The nurse is discussing measures to minimize the risk of injury from an automobile accident with an 83-year-old adult client who lives alone and claims to drive only to church, the doctors office, and for groceries. Which of the following suggestions has the greatest potential for affecting this clients safety?

1.

Take public transportation whenever it is available.

2.

Plan errands around church or doctors appointments.

3.

Plan driving for short trips and only during the daylight hours.

4.

Arrange for family or friends to drive you whenever it is possible.

ANS: 3

The nurse educates clients regarding safe driving tips (e.g., driving shorter distances or only in daylight, using side and rearview mirrors carefully, and looking behind them toward their blind spot before changing lanes). The other options, while not incorrect, may not be realistic or appealing to an independent client.

PTS: 1 DIF: C REF: 824 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

31. Which of the following assessment findings is most critical in a client who is currently being restrained with mechanical wrist restraints?

1.

Angry, loud crying

2.

Urinary incontinence

3.

Reddened areas on wrists

4.

Hands are cool to the touch

ANS: 4

While the use of any restraint may be associated with serious complications, including pressure ulcers, constipation, pneumonia, urinary and fecal incontinence, and urinary retention, the most serious are contractures, nerve damage, and circulatory impairment. The coolness of the clients hands indicates poor circulation and can result in permanent damage.

PTS: 1 DIF: C REF: 837 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

32. The nurse is discussing a newly ordered diuretic with an older adult client who is home-bound. Which of the following suggestions has the greatest potential for minimizing the clients risk for injury related to urinary urgency or incontinence?

1.

Consider decreasing fluid intake after 6 PM.

2.

Illuminate the path to the bathroom at night.

3.

Encourage the client to urinate immediately before bed.

4.

Encourage the client to take the medication early in the morning.

ANS: 4

Nocturia and incontinence are more frequent in older adults. Give diuretics in the morning. While the other options may have value, they do not have an impact on the situation as directly as the administration of the medication.

PTS: 1 DIF: C REF: 813 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

33. A nurse caring for an elderly client who has had surgery and is in the hospital knows that the client is at high risk for developing a nosocomial infection. One of the most important things that the nurse can do to prevent this client from obtaining a nosocomial infection is to:

1.

Practice appropriate hand hygiene

2.

Request prophylactic antibiotics for the client

3.

Place the client in isolation

4.

Encourage the client to turn, cough and deep breath every 2 hours

ANS: 2

Antibiotics should be used appropriately to prevent resistant organisms. The best way to prevent nosocomial infections is to perform hand hygiene before and after each client encounter and after contact with contaminated objects. Isolation will not in itself prevent a nosocomial infection. Answer 4 will help prevent atelectasis, but not necessarily a nosocomial infection.

PTS: 1 DIF: B REF: 829 OBJ: Application

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

34. The nurse caring for an elderly client in the hospital notes on assessment that the client has a scald burn on her foot. On questioning the client, the nurse learns that the client scalded her foot when adding hot water from the tap to her bath while she was in the tub. The nurse should do which of the following?

1.

Report the incident as suspected elder abuse.

2.

Suggest that the temperature of the hot water heater be lowered.

3.

Instruct the client that she should not be taking tub baths to prevent this from happening again.

4.

Discuss the incident with social services so that arrangements can be made for the client to go to a nursing home on discharge from the hospital.

ANS: 2

Hot water from the tap should not have the potential to scald, because it is a safety hazard. The client had a plausible explanation for the incident without other signs to indicate abuse. There is no reason that the client should not be able to continue to take tub baths if the water temperature is within a safe range. The client has no other indications that she is in any danger of caring for herself; thus Answer 4 is not appropriate.

PTS: 1 DIF: A REF: 824 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

35. A nurse in the emergency department (ED) of a community hospital notes that an unusually high number of clients have presented in the ED with flulike symptoms, abdominal pain, nausea, vomiting, bloody diarrhea, hematemesis and itching of the hands, forearms, and head. The nurse is concerned with bioterrorism, reports this to the supervisor, and suspects an outbreak of:

1.

Botulism

2.

Anthrax

3.

Plague

4.

Smallpox

ANS: 2

The symptoms of the clients all point to an endemic outbreak of anthrax.

PTS: 1 DIF: A REF: 816 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

36. When discussing the new mothers pending discharge from the hospital, the nurse determines that additional client teaching needs to take place because of which of the following comments?

1.

My husband has installed the new car seat in the middle of the backseat of our car.

2.

I cant wait to put my baby in her new crib with the ensemble that my mom made sheets, blankets, and bumper to match.

3.

I need to place my baby on her back to sleep, right?

4.

I have checked all my babys toys to make sure that they dont contain lead paint.

ANS: 2

Newborns should not be placed in cribs with loose comforters, bumper pads, etc. The middle of the back seat is the safest place to put the infant car seat. Babies should not be placed on their stomachs with their mouth and nose in close proximity to the mattress, which is associated with sudden death syndrome. Lead paint on infant toys can lead to brain damage.

PTS: 1 DIF: A REF: 829 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

37. A confused client on a ventilator was restrained to prevent him from pulling out his endotracheal tube. Which of the following could be a possible alternative measure that the nurse could use to avoid the use of the restraints?

1.

Orient the client to the environment and explain the need for the endotracheal tube.

2.

Provide a trained sitter to continuously supervise the client.

3.

Camouflage the endotracheal tube with stockinette dressing.

4.

Promote relaxation techniques.

ANS: 2

A trained sitter can prevent the client from pulling out the endotracheal tube. The client is confused and does not understand. The endotracheal tube cannot be camouflaged effectivelythe client feels it more than sees it. Because the client is confused, it may be very difficult to communicate relaxation techniques so that the client has an understanding.

PTS: 1 DIF: C REF: 821 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

38. A confused client needs to have restraints to prevent him from pulling out his Foley catheter. Which of the following can the nurse delegate to the nursing assistive personnel?

1.

Applying restraints

2.

Obtaining a physicians order to restrain the client

3.

Document the events that led to restraining the client

4.

Evaluating the effectiveness of the restraints

ANS: 1

Although the nursing assistive personnel can apply the restraints under the nurses direction, they cannot document, evaluate, or take physicians orders.

PTS: 1 DIF: A REF: 826 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

39. A nurse finds that an electrical cord has shorted out in a clients room, causing a fire. The nurse should do which of the following actions first?

1.

Activate the alarm.

2.

Confine the fire by closing the clients door.

3.

Remove the client from the room.

4.

Extinguish the fire.

ANS: 3

The mnemonic RACE should be used to help remember to rescue or remove all clients in immediate danger, activate the alarm, confine the fire, and extinguish the fire

PTS: 1 DIF: A REF: 832 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

40. Which of the following statements indicates that the client is at risk for an electrical shock at home?

1.

I had to cut off the third prong on the electrical plug so that it would fit in the extension cord.

2.

My bread got stuck in my toaster this morning, and I unplugged it before trying to remove it.

3.

I always read the owners manual when I purchase a new electrical appliance.

4.

I always make sure that I am standing in a dry area before operating electrical equipment.

ANS: 2

The third prong is used to ground the piece of equipment. Improperly grounded equipment can cause electrical injury.

PTS: 1 DIF: B REF: 834 OBJ: Application

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

41. The nurse is caring for a client with a history of epileptic seizures. The nursing assistive personnel notifies the nurse that the client is having a seizure. The first thing that the nurse should do when arriving in the room is to:

1.

Raise the bed side rails

2.

Put the bed in the lowest position

3.

Position the client safely

4.

Provide privacy

ANS: 3

Although Answers 1, 2 and 3 are all important safety interventions, the priority is to safely position the client. It is important to provide privacy, but safety interventions are a priority.

PTS: 1 DIF: B REF: 840 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

42. A client with a history of epilepsy arrives in the emergency department experiencing status epilepticus. The nurse should never do which of the following?

1.

Document sequence of events, including any adverse outcomes.

2.

Prepare to initiate IV access.

3.

Access oxygen and suctioning equipment.

4.

Open clients mouth by placing fingers on jaw and inserting thumb on bottom teeth to place oral airway between seizures.

ANS: 4

Nurses should never put their fingers in or close to a clients mouth who is or has been experiencing seizure activity, to prevent being bitten in the event that the client should experience more seizure activity. The nurse is responsible for all of these measures in Answers 1, 2, and 3 to provide for the safety of the client, as well as document the sequence of events including any unexpected outcomes.

PTS: 1 DIF: B REF: 842 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

MULTIPLE RESPONSE

1. The nurse caring for clients in an acute care facility recognizes that attending to the safety of each client is most likely to result in: (Select all that apply.)

1.

Freedom from illness

2.

A shorter hospital stay

3.

Attention to the basic human needs

4.

A well-founded sense of well-being

5.

Preservation of the optimal functioning level

6.

Minimal exposure to bacterial cross-contamination

ANS: 2, 3, 4, 5, 6

Safety in health care settings reduces the incidence of illness and injury, prevents extended length of treatment and/or hospitalization, improves or maintains a clients functional status, and increases the clients sense of well-being. A safe environment gives protection to the staff as well, allowing them to function at an optimal level. A safe environment includes meeting basic needs, reducing physical hazards, reducing the transmission of pathogens, maintaining sanitation, and controlling pollution. While a reduction of illness is an expectation, there is no assurance of the freedom from illness.

PTS: 1 DIF: A REF: 843 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

2. The nurse recognizes that children living in older housing that may contain lead-based paints may exhibit which of the following signs and symptoms? (Select all that apply.)

1.

Vomiting

2.

Anorexia

3.

Headaches

4.

Bloody urine

5.

Thoracic rash

6.

Swollen joints

ANS: 1, 2, 3

Signs and symptoms of lead poisoning typically include impaired hearing, vomiting, headaches, appetite loss, and learning and behavioral problems. The remaining options are not typically seen with this condition.

PTS: 1 DIF: C REF: 844 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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