Client Safety
A nurse is caring for a client who fell at a nursing
home. The client is oriented to person, place,
and time and can follow directions. Which of the
following actions should the nurse take to decrease
the risk of another fall? (Select all that apply.)
A. Place a belt restraint on the client when they
are sitting on the bedside commode.
B. Keep the bed in its lowest position
with all side rails up.
C. Make sure that the client’s call light is within reach.
D. Provide the client with nonskid footwear.
E. Complete a fall‑risk assessment.
C. CORRECT: Making sure that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light.
D. CORRECT: Nonskid footwear keeps the client from slipping.
E. CORRECT: A fall‑risk assessment serves as the basis for a plan of care that can then individualize for the client
To use a fire extinguisher, use the PASS sequence.
P: Pull the pin.
A: Aim at the base of the fire.
S: Squeeze the handle.
S: Sweep the extinguisher from side to side, covering the area of the fire.
What rescue equipment is at the bedside?
oxygen,
an oral airway,
suction equipment,
padding for the side rails
saline lock
2 types of restraints?
physical
chemical
Who are at the greatest risk for falls?
Older adult clients can be at an increased risk for falls due to decreased strength, impaired mobility and balance, improper use of mobility aids, unsafe clothing, environmental hazards, endurance limitations, and decreased sensory perception
A nurse manager is reviewing with nurses on
the unit in the care of a client who has had a
seizure. Which of the following statements
by a nurse requires further instruction?
A. “I will place the client on their side.”
B. “I will go to the nurses’ station for assistance.”
C. “I will note the time that the seizure begins.”
D. “I will prepare to insert an airway.”
B. CORRECT: During a seizure, stay with the client and use the call light to summon assistance
Fire response follows the RACE sequence
R: Rescue and protect clients in close proximity to the fire by moving them to a safer location. Clients who are ambulatory can walk independently to a safe location.
A: Alarm: Activate the facility’s alarm system and then report the fire’s details and location.
C: Contain/Confine the fire by closing doors and windows and turning off any sources of oxygen and any electrical devices. Ventilate clients who are on life support with a bag-valve mask.
E: Extinguish the fire if possible using the appropriate fire extinguisher.
Do you put anything in the clients mouth during a seizure
yes or no
no
What medical complications can restraints cause
pneumonia,
incontinence,
pressure injuries
Why must health care facilities actively prevent falls?
Medicare and Medicaid no longer reimburse for treating injuries resulting from falls.
A nurse observes smoke coming from under
the door of the staff’s lounge. Which of the
following actions is the nurse’s priority?
A. Extinguish the fire.
B. Activate the fire alarm.
C. Move clients who are nearby.
D. Close all open doors on the unit.
C. CORRECT: The greatest risk to this client is injury from the fire.
Therefore, the priority intervention is to rescue the clients.
Protect and move clients in close proximity to the fire.
FIRE SAFETY-All staff must know 3 things?
1.Know the location of exits, alarms, fire extinguishers, and oxygen shut‑off valves.
2.Make sure equipment does not block fire doors.
3. Know the evacuation plan for the unit and the facility.
What should the nurse do to protect the client during a seizure?
lower the client to the floor or bed
Protect their head,
Remove nearby furniture,
Provide privacy,
Put them on one side with the head flexed slightly forward if possible
Loosen their clothing.
In an emergency situation when there is immediate risk to the client or others, nurses can place restraints on a client. When does the nurse obtain the order?
The nurse must obtain a prescription from the provider as soon as possible according to the facility’s policy (usually within 1 hr).
When do you complete a fall risk assessment?
Complete a fall-risk assessment for each client at
admission and at regular intervals
A nurse is caring for a client who has a history of falls.
Which of the following actions is the nurse’s priority?
A. Complete a fall‑risk assessment.
B. Educate the client and family about fall risks.
C. Eliminate safety hazards from
the client’s environment.
D. Make sure the client uses assistive
aids in their possession.
. A. CORRECT: The first action to take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client’s fall risk. This will work as a guide in implementing appropriate safety measures
Classes of fire extinguishers
Class A is for combustibles (paper, wood, upholstery, rags, other types of trash fires).
Class B is for flammable liquids and gas fires. Class C is for electrical fires.
During a seizure what is important to note as the nurse?
The duration of the seizure and the sequence and type of movements
How long can a person be in restraints?
4 hours with a max of 24 hours to renew.
What are ways nurses can help clients prevent falls in the hospital?
Use of call light and within reach of client
Color coded wrist bans
Adequate lighting
Hourly rounding
Close room to nurses desk
Nonskid footwear
Keep floor free of clutter
Orient patient to room
A nurse discovers a small paper fire in a trash can
in a client’s bathroom. The client has been taken
to safety and the alarm has been activated. Which
of the following actions should the nurse take?
A. Open the windows in the client’s
room to allow smoke to escape.
B. Obtain a class C fire extinguisher
to extinguish the fire.
C. Remove all electrical equipment
from the client’s room.
D. Place wet towels along the base of
the door to the client’s room.
D. CORRECT: Place wet towels along the base of the door to the client’s room to contain the fire and smoke in the room
What does code red mean
Fire, smoke, or smell of smoke.
After a clients seizure what should the nurse do?
Determine mental status
Measure oxygenation saturation and vital signs.
Explain what happened, and provide comfort, understanding, and a quiet environment for recovery
Document the seizure with any precipitating behavior and
a description of the event (movements, injuries, duration of seizures, aura, postictal state), and report it to the provider
The physician order must include what?
reason for the restraints,
the type of restraints,
the location of the restraints,
how long to use the restraints,
the type of behavior that warrants using the restraints
What is an example of a sentinel event
wrong-site surgery,
foreign body retention,
falls