Safety
The nurse is making a home visit and is wearing a scrub top, scrub pants, and a windbreaker when the outside temperature is 45°F.
Which safety concern should the nurse consider regarding clothing choice?
A.The nurse will be too warm in this outfit.
B.The nurse should dress in layers in case the home is poorly heated or without heat.
C.The nurse's clothing is appropriate for the weather.
D.The nurse should wear business attire.
B.The nurse should dress in layers in case the home is poorly heated or without heat.
Rationale: Home care nurses need to protect their own health. They often enter poorly heated or cooled homes. Their attire should provide appropriate thermoregulation even if the client surroundings are dangerous to health.
While conducting a home visit, the nurse observes a new mother heat the water to the proper temperature, place the infant in a sink for a morning bath, and then walk away to collect towels and soap. Which topic should the nurse use to guide teaching for this mother?
A.Thermoregulation issue
B.Knowledge deficit
C.Risk for developmental delays
D.Risk for coping issues
B.Knowledge deficit
Rationale: The mother may not be aware that the baby can drown in a sink full of water, so the topic of knowledge deficit is correct. The nurse would need to teach the mother about water safety for the infant. Nothing indicates the infant is having thermoregulation issues, so this topic would not be applicable at this time. Neither the mother nor the infant has sustained a head injury, so the risk for developmental delays is not applicable at this time. There is no evidence to suggest that the mother is at risk for coping issues.
A patient comes into the ER with the complaint of inability to void. The nurse performs a bladder scan and receives a result of 2,000 mL. The nurse prepares to catheterize the patient and knows that the most important part of the procedure relies on:
A. Allowing the patient to attempt to void after 500mL has been drained.
B. Teaching the patient how to self-catheterize themselves at home.
C. Educating the patient about possible causes of inability to void.
D. Clamping the tubing after every 500mL is drained and waiting five minutes.
D. Clamping the tubing after every 500mL is drained and waiting five minutes.
Clamping the tubing after each 500mL prevents bladder spasms, which are painful and not good for the bladder.
The nurse at the daycare center observes children playing on the playground. The nurse is MOST concerned if which of the following is observed?
A. Two children are fighting over a ball.
B. One child tries to pull another off the swing.
C. A 2-year-old is crying, tugging at his ear, and hugging a stuffed animal.
D. A 3-year-old is leaning forward with mouth open, tongue protruding, and drooling.
D. A 3-year-old is leaning forward with mouth open, tongue protruding, and drooling.
Children fighting over balls or pulling others off of swings are normal safety issues of child development and play. The child crying while tugging at his ear depicts classic signs of an earache or ear infection. The child leaning forward with mouth open, tongue protruding, and drooling is the most immediate threat to safety because it describes signs of epiglottitis where the child is in danger of losing his or her airway.
The nurse obtains information during the admission interview that the patient is taking dietary supplements in addition to prescribed medications. What is the nurse’s primary concern for this patient?
1.Dietary supplements are natural and pose no risk
to the patient but may be costly.
2.Dietary supplements are a welcome addition to
conventional medications but do not always come
with instructions.
3.The patient may be at risk for allergic reactions.
4.Dietary supplements may interact with prescribed
medications and affect drug action
4.Dietary supplements may interact with prescribed
Rationale: Some dietary supplements contain ingredients that may serve as agonists or antagonists to prescription drugs. Dietary supplements should not be taken without discussing their use with the health-care provider. Options 1, 2, and 3 are incorrect. Dietary supplements may be natural but not all of them are safe or effective, and they may vary greatly in cost. Most dietary supplements, like medications, come with instructions. Dietary supplements may cause an allergic reaction as prescribed medications do, but because this patient has been taking the supplements without report of allergy, the nurse’s primary concern would be interactions between the prescribed medications and the supplements
The nurse is teaching a class about workplace violence. Which example of violence should the nurse include? (Select all that apply.)
A.A client who throws his tray at the aide
B.A healthcare provider who is convicted of domestic violence
C.A staff member being bullied by several people on the unit
D.A nurse whose husband hits her every evening
E.A family member who threatens to shoot the receptionist
A.A client who throws his tray at the aide
C.A staff member being bullied by several people on the unit
E.A family member who threatens to shoot the receptionist
Rationale: Workplace violence is defined as any threatening action or violent act that takes place in a workplace. The client who throws his tray at staff, the family member who threatens a staff member's life, and staff members bullying a fellow employee are all examples of workplace violence. The examples of domestic violence, whether the employee is a perpetrator or a victim, are not workplace violence because they take place in the home and not in the workplace.
The nurse finds a 14-year-old client watching MTV at full blast. Which safety issue should the nurse address with the client?
A.Adolescents need to be reminded that loud music can lead to hearing loss.
B.It is inappropriate for the client to watch MTV.
C.The noise is making it hard for the nurse to chart.
D.It is not wise for the client to argue with parents about watching MTV.
A.Adolescents need to be reminded that loud music can lead to hearing loss.
Although the noise may be disturbing the nurse's work and the client's parents may not want the client to watch MTV at high volume, these are not the safety concerns the nurse needs to address. Listening to music and television at a high-decibel volume can lead to hearing loss.
The hospital uses a common disinfectant wipe that is rumored to cause cancer. Which appropriate step should the hospital take to ensure worker and community safety? (Select all that apply.)
A.Instruct workers to stop disinfecting surfaces until the safety issue is solved.
B.Throw all the wipes away in the garbage.
C.Join Go Green to learn about safe environmental disposal of hazardous substances.
D.Encourage use of gloves while handling hazardous substances.
E.Research the effectiveness of safer disinfectants and replace the hazardous chemical.
C.Join Go Green to learn about safe environmental disposal of hazardous substances.
D.Encourage use of gloves while handling hazardous substances.
E.Research the effectiveness of safer disinfectants and replace the hazardous chemical.
Rationale: The hospital should investigate the safety of this product and look for safer disinfectants if needed. In the meantime, employees should be instructed to use gloves to minimize risk. The hospital should also join Go Green or another environmental initiative to learn about safe disposal of hazardous medical waste. However, discontinuing disinfecting practices until safer alternatives are found will increase the risk of healthcare-associated infections (HAIs). Throwing wipes away in the garbage could pose an environmental risk if they are indeed carcinogenic.
The medical/surgical nurse cares for a middle-aged patient with an open wound infected with MRSA (Methicillin-resistant Staphylococcus aureus). The nurse is changing the bandage. Which of the following protective safety items, if worn by the nurse, would be considered appropriate?
A. A gown and gloves.
B. Shoe covers, a gown, and gloves.
C. Gloves only.
D. A mask, gown, and gloves.
A. A gown and gloves.
A patient infected with MRSA requires contact precautions. Gown and gloves constitute contact precautions.
Appropriate teaching to provide safety for a patient who is planning to use herbal products should include which of the following?
1. Take the smallest amount possible when starting
herbal therapy, even less than the recommended
dose, to see if allergies or other adverse effects
occur.
2.Read the labels to determine composition of the
product.
3.Research the clinical trials before using the
products.
4.Consult the internet or herbal store staff to deter-
mine the safest dose and length of time the dose
should be taken
1. Take the smallest amount possible when starting herbal therapy, even less than the recommended dose, to see if allergies or other adverse effects occur.
Rationale:
Natural products contain many
active ingredients, many of which have not been tested
or identified. Patients with known allergies to food
products or medicines should seek medical advice
before using herbal supplements. Options 2, 3, and 4
are incorrect. Dietary supplements must state that the
product is not intended to diagnose, treat, cure, or pre-
vent any disease. Herbal products have not been subject to the rigorous clinical trials that approved drugs
have, and the internet or herbal store personnel are
not the definitive authorities on the product or its use,
effectiveness, or safety. The patient should be encouraged to consult the healthcare provider for any questions related to the herbal product
The nurse is caring for a client with Down syndrome who likes to say "hi" to everyone and strike up conversations. Which important safety information should the nurse teach the caregivers?
A.Keep the client in a restrictive environment.
B.Monitor the client's interactions to make sure the client is engaging with safe people.
C.Tell the client not to bother strangers.
D.Make sure to tell the client to shake hands with strangers.
B.Monitor the client's interactions to make sure the client is engaging with safe people.
The client's caregivers will need to monitor the client's interactions with strangers because the client may have no awareness that some people can be dangerous. The client has a right to be in the least restrictive environment, and if the client's social interactions can be safely supervised, socialization is beneficial for the client. Teaching the client to shake hands is not a safety consideration. Telling the client not to bother strangers is not therapeutic and could cause harm to the client's feelings.
Which intervention should the nurse implement as a standard safety measure for adult clients? (Select all that apply.)
A.Alerting the nurse to changes in pain or physical condition
B.Maintaining proper fluid intake
C.Teaching clients to disconnect their oxygen when getting out of bed to walk
D.Encouraging use of the call button
E.Encouraging clients to use proper hand hygiene
A.Alerting the nurse to changes in pain or physical condition
B.Maintaining proper fluid intake
D.Encouraging use of the call button
E.Encouraging clients to use proper hand hygiene
Which action by the nurse risks a needlestick injury? (Select all that apply.)
A.Attempts to put a needle into a full sharps container
B.Places a needle in an unapproved disposal device
C.Uses improper hand technique in administering shots
D.Gives several shots every day
E.Recaps a dirty needle
A.Attempts to put a needle into a full sharps container
B.Places a needle in an unapproved disposal device
C.Uses improper hand technique in administering shots
E.Recaps a dirty needle
Rationale: If nurses use proper handling, delivery, and disposal techniques, they can very safely administer many shots throughout the day. However, recapping a dirty needle presents a risk for not only a needlestick but contamination from HIV, hepatitis, or other diseases. Using improper hand technique creates a risk that fingers will get in the way. If the nurse tries to put a dirty needle in a full sharps container, it can ricochet back and stab the nurse. Finally, disposing of a needle in the trash is dangerous because it could lead to needlestick injuries in environmental workers.
A licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the LPN to intervene?
A. The assistant places a gait belt around the client’s waist prior to ambulating.
B. The assistant places the client on the back with the client’s head to the side.
C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.
D. The assistant praises the client for attempting to perform ADLs independently.
C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.
This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety. All the other actions are appropriate.
What is the difference between an herbal product and a specialty supplement?
1. An herbal product is safer to use than a specialty
supplement.
2. A specialty supplement tends to be more expensive than an herbal product.
3.A specialty supplement is a non herbal dietary
product used to enhance a variety of body
functions.
4.There are less adverse effects or risk of allergy
with specialty supplements than there are with
herbal products
3.A specialty supplement is a non herbal dietary
product used to enhance a variety of body
functions.
Specialty supplements are non herbal dietary products used to enhance a wide variety of body functions. In general, specialty supplements have a legitimate rationale for their use. But the link between most specialty supplements and their claimed benefits is unclear and the body may already have sufficient quantities of the substance. Options 1, 2, and 4 are incorrect. A specialty supplement may not be safer or more expensive than an herbal supplement and may carry the same risk of adverse effects as an herbal product
The nurse is caring for a 9-year-old client who was injured while riding a bicycle down a steep hill while the client's mother was at work. Which underlying safety issue should the nurse address? (Select all that apply.)
A.Determine the nutritional status of the child.
B.Review the physical and emotional needs of latchkey children with the mother.
C.Investigate possible emotional triggers for risky behavior, such as choosing to bike down a steep hill.
D.Address whether a peer group is encouraging risky behavior.
E.Review the importance of wearing protective gear, such as helmets and long-sleeved clothing, while riding bicycles.
B.Review the physical and emotional needs of latchkey children with the mother.
C.Investigate possible emotional triggers for risky behavior, such as choosing to bike down a steep hill.
D.Address whether a peer group is encouraging risky behavior.
E.Review the importance of wearing protective gear, such as helmets and long-sleeved clothing, while riding bicycles.
The nurse should review bicycle safety, peer involvement, latchkey children's emotional needs, and reasons for risky behavior. Bicycle safety is important given the history of a serious accident. School-age children are often "latchkey" children, old enough to stay alone while a mother is at work, but they have physical and emotional needs that need to be addressed carefully. Otherwise, they may find a negative peer group or engage in risky behaviors to act out. The nutritional status of the child is not relevant to risk for injury.
The nurse is teaching new mothers about safe sleeping for newborns. Which recommendation should the nurse include
A.Keep newborns on their stomachs while in the crib and cover them with a warm blanket.
B.Cover newborns up to the shoulder with a warm blanket and put them on their backs.
C.Place newborns on their sides and cover with a light blanket.
D.Dress newborns in warm clothing and place them on their backs while in a crib
D.Dress newborns in warm clothing and place them on their backs while in a crib
Research has shown that the best way to prevent sudden infant death syndrome (SIDS) is to place infants in a crib or bassinette on their backs. Dress the infant in warm clothing and do not use blankets because they could move out of position and smother the infant. Infants should not be placed on their stomachs or sides.
Which measure should the nurse suggest for toddler-proofing a home? (Select all that apply.)
A.Storing and locking up cleaning supplies and medications out of reach
B.Cutting foods properly to prevent choking hazards
C.Choosing age-appropriate toys that do not pose a swallowing hazard or injury risk
D.Placing toddlers on their backs in bed, without blankets and in warm clothing
E.Providing gym equipment on a hard surface
A.Storing and locking up cleaning supplies and medications out of reach
B.Cutting foods properly to prevent choking hazards
C.Choosing age-appropriate toys that do not pose a swallowing hazard or injury risk
Rationale: Choking, injuries, and poisoning are primary concerns for toddler safety. Toys should be age-appropriate so that toddlers cannot swallow them and block an airway or injure themselves on sharp corners. Food should be cut properly to prevent choking. Cleaning supplies and medications need to be locked away and out of reach to prevent poisoning. Positioning toddlers in bed without blankets and on their backs is inappropriate; this intervention prevents sudden infant death syndrome (SIDS) in babies, but children need warmth from blankets and can sleep in any position. Gym equipment should be placed on a soft surface so that children will not be injured from falls.
The disseminated herpes zoster virus requires a nurse to follow ________ precautions at all times.
Airborne precautions are added for clients who have illnesses that are transmitted by airborne droplet nuclei, such as chickenpox during the early stage of infection.
An older adult patient tells the nurse that she has been using several herbal products recommended by a friend. Why would the nurse be concerned with this statement, given the patient’s age?
1.The older adult patient may have difficulty reading labels and opening bottles and may confuse
medications.
2.The older adult patient may have difficulty paying for additional medications and may stop
using prescribed drugs.
3.The older adult patient may be more prone to
allergic reactions from herbal products.
4.The older adult patient may have other disease
conditions that could increase the risk for a drug
reaction
4.The older adult patient may have other disease
conditions that could increase the risk for a drug
reaction
The older adult patient is more likely to have chronic ailments such as kidney, cardiac, or liver disease that could increase the risk for a drug–herb interaction. Options 1, 2, and 3 are incorrect. Not all older adult patients have difficulty with reading labels, opening bottles, or financial concerns that would affect the ability to obtain prescribed medication. When these situations occur, the nurse should assess the impact they have on the patient’s ability to safely take medication. Older adults are not more prone to develop allergies from an herbal product and may be less sensitive to allergens, due to a declining immune system.
During physical therapy, the nurse notices that an older adult client keeps tripping and bumping into things while walking. Which important safety measure should the nurse implement? (Select all that apply.)
A.Encouraging use of a gait belt
B.Asking for a guide dog to accompany the client
C.Finding out when the client last had an eye exam and prescription glasses adjustment and referring for a vision check
D.Reminding the client to use assistive walking devices
E.Asking the physical therapist to cue the client when floor surfaces change and unexpected objects appear in the client's path
A.Encouraging use of a gait belt
C.Finding out when the client last had an eye exam and prescription glasses adjustment and referring for a vision check
D.Reminding the client to use assistive walking devices
E.Asking the physical therapist to cue the client when floor surfaces change and unexpected objects appear in the client's path
Rationale: The client is showing signs of poor vision because the client is tripping and bumping into objects when walking. The nurse should proactively work on obtaining a vision exam and new glasses prescription. In the meantime, for safety, the nurse needs to remind the client to use a walker or cane to maintain balance. Remind the therapist to cue the client to unexpected changes in the walking surface. Encourage the client to use a gait belt to keep the client safe from sudden falls. Use of a guide dog is an inappropriate intervention without an eye exam that provides evidence of blindness.
The nurse taught a group of high school students actions to prevent injury. Which student comment indicates an understanding of the teaching? (Select all that apply.)
A."I do not need to wear a seat belt as a passenger in a car."
B."If I feel really down, I need to talk to my parents about it."
C."I hate it, but I will wear a helmet when riding my bike."
D."I should not get into a car when the driver has been drinking."
E."I can talk to a teacher if I am faced with peer pressure to use drugs."
A."I do not need to wear a seat belt as a passenger in a car."
B."If I feel really down, I need to talk to my parents about it."
C."I hate it, but I will wear a helmet when riding my bike."
E."I can talk to a teacher if I am faced with peer pressure to use drugs."
Rationale: Nursing actions to reduce the risk for unintentional injury in the adolescent include teaching on the use of seat belts and helmets, discussing drug and alcohol use and risk for suicide, and discussing the risk for traumatic brain injury. The student who states there is no need to wear a seat belt as a passenger in a car would require further teaching. The statements of the other students indicate that teaching has been effective.
The nurse is caring for clients who have dementia on a locked unit. Which is an important safety issue for the nurse to remember during daily work? (Select all that apply.)
A.Residents need regular exercise to maintain muscle strength and joint flexibility.
B.If the unit is locked, the environment is safe, and no issues exist.
C.Medications should be locked away to prevent impaired clients from accidental ingestion and errors.
D.Cognitively impaired adults are at risk for falls.
E.Residents should be allowed to leave the unit independently.
A.Residents need regular exercise to maintain muscle strength and joint flexibility.
C.Medications should be locked away to prevent impaired clients from accidental ingestion and errors.
D.Cognitively impaired adults are at risk for falls.
There are many safety risks to address even if the unit is on lockdown. First, clients should not be allowed to leave unaccompanied; by definition, they need to be under supervision, or they would not be placed on this unit. Risks on the unit include the following: fall risks due to cognitive impairment; fall risks from muscle atrophy and achy joints, which can be mitigated by regular exercise; and the risk of impaired residents getting into medication.
The home health nurse visits the home of a client diagnosed with moderate-stage Alzheimer’s disease. The patient is pleasantly confused and lives with his son-in-law and daughter. Which of the following observations, if made by the nurse, is MOST concerning?
a. The door has a lock with a bolt.
b. The rugs are secured safely to the floor.
c. There are extension cords on the floors behind furniture.
d. The stovetops do not turn on without activation of a hidden switch in the nearby drawer.
a. The door has a lock with a bolt.
Doors need to have locks in atypical locations (eg, tops of doors) to prevent the patient from nighttime confused wandering.
Which patients may be most at risk for adverse effects
related to specialty supplements? (Select all that
apply.)
1.Adolescents
2.Pregnant women
3.School-age children
4.Older adult patients
5.Patients taking prescription medications
2.Pregnant women
4.Older adult patients
5.Patients taking prescription medications
Rationale: Pregnant women, older adult patients, and patients who are taking prescription medications, especially those with a narrow safety profile, are at greatest risk for adverse effects related to specialty supplements. Some supplements may cross the placenta with unknown effects on the developing fetus. Older adult patients may have con-current disease conditions or a decline in organ function that would affect the safety of the supplement. Drug–supplement interactions may occur, especially with drugs with narrow safety profiles. Options 1 and3 are incorrect. Adolescents and school-age children are not at increased risk for adverse effects unless other disease conditions or concurrent medications increase that risk.