1. A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?
a. “Every December is the time to change batteries on the carbon monoxide detector.”
b.
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1. A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?
a. “Every December is the time to change batteries on the carbon monoxide detector.”
b. “I will schedule an appointment with a chimney inspector next week.”
c. “If I feel dizzy when using the heater, I need to have it inspected.”
d. “When it is cold outside in the winter, I will use a nonvented furnace.”
ANS: D
Using a nonvented heater introduces carbon monoxide into the environment and decreases the available oxygen for human consumption and the nurse should follow up to correct this behavior. Checking the chimney and heater, changing the batteries on the detector, and following up on symptoms such as dizziness, nausea, and fatigue are all statements that are safe and appropriate and need no follow-up.
DIF:Analyze (analysis)REF:374
OBJ: Describe environmental hazards that pose risks to a person’s safety.
TOP: Assessment MSC: Safety and Infection Control
2. The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient’s health care needs?
a. The electricity was turned off 3 days ago.
b. The water comes from the county water supply.
c. A son and family recently moved into the home.
d. This home is not furnished with a microwave oven.
ANS: A
Electricity is needed for refrigeration of food, and lack of electricity could have contributed to the nausea, vomiting, and diarrhea due to food poisoning. This discussion about the patient’s electrical needs can be referred to social services. Foods that are inadequately prepared or stored or subject to unsanitary conditions increase the patient’s risk for infections and food poisoning, and an assessment should include storage practices. The water supply, the increased number of individuals in the home, and not having a microwave may or may not be concerns but do not pertain to the current health care needs of this patient.
DIF:Analyze (analysis)REF:374 | 381 | 388
OBJ: Describe environmental hazards that pose risks to a person’s safety.
TOP:PlanningMSC:Management of Care
3. The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?
a. 60° to 64° F
b. 65° to 75° F
c. 15° to 17° C
d. 25° to 28° C
ANS: B
A person’s comfort zone is usually between 18.3° and 23.9° C (65° and 75° F). The other ranges are too low or too high and do not reflect the average person’s comfort zone.
DIF:Understand (comprehension)REF:374
OBJ: Describe environmental hazards that pose risks to a person’s safety.
TOP: Implementation MSC: Basic Care and Comfort
4. A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
a. Respiratory rate
b. Temperature
c. Apical pulse
d. Blood pressure
ANS: B
The temperature indicates the patient is experiencing hypothermia. Homeless individuals are more at risk for hypothermia. While all the vital signs are low, the most critical vital sign at this time is the temperature.
DIF:Analyze (analysis)REF:374
OBJ: Describe environmental hazards that pose risks to a person’s safety.
TOP: Assessment MSC: Reduction of Risk Potential
5. A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?
a. Wash hands
b. Wash wound
c. Wear gloves
d. Wear eye protection
ANS: A
One of the most effective methods for limiting the transmission of pathogens is the medically aseptic practice of hand hygiene. The most common means of transmission of pathogens is by the hands. While washing the wound is needed, the best method to prevent transmission is hand hygiene. Wearing gloves and possibly eye protection help protect the nurse, but handwashing is best for limiting the transmission of pathogens.
DIF:Understand (comprehension)REF:375
OBJ: Discuss methods to reduce physical hazards and the transmission of pathogens.
TOP: Teaching/Learning MSC: Safety and Infection Control
6. The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event?
a. No blood incompatibility occurs with a blood transfusion.
b. A surgical sponge is left in the patient’s incision.
c. Pulmonary embolism after lung surgery
d. Stage II pressure ulcer
ANS: B
The Centers for Medicare and Medicaid Services names select serious reportable events as Never Events (i.e., adverse events that should never occur in a health care setting). A surgical sponge left in a patient’s incision is a Never Event. No blood incompatibility reaction is safe practice. Pulmonary embolism after certain orthopedic procedures is like a total knee and hip replacement. Stage III and IV pressure ulcers are Never Events.
DIF:Understand (comprehension)REF:377-378
OBJ: Discuss the importance of consensus standards for public reporting of patient safety events.
TOP:ImplementationMSC:Management of Care
7. The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next?
a. Do nothing, no harm has occurred.
b. Notify the health care provider.
c. Complete an incident report.
d. Assess the patient.
ANS: B
Report immediately to physician or health care provider if the patient sustains a fall or an injury. The nurse must provide safe care, and doing nothing is not safe care. The scenario indicates the nurse has already assessed the patient. After the patient has stabilized, completing an incident report would be the last step in the process.
DIF:Apply (application)REF:399
OBJ: Define the knowledge, skills, and attitudes necessary to promote safety in a health care setting.
TOP: Implementation MSC: Safety and Infection Control
8. When making rounds the nurse observes a purple wristband on a patient’s wrist. How will the nurse interpret this finding?
a. The patient is allergic to certain medications or foods.
b. The patient has do not resuscitate preferences.
c. The patient has a high risk for falls.
d. The patient is at risk for seizures.
ANS: B
In 2008 the American Hospital Association issued an advisory recommending that hospitals standardize wristband colors: red for patient allergies, yellow for fall risk, and purple for do not resuscitate preferences. Purple does not indicate seizures.
DIF:Understand (comprehension)REF:390
OBJ: Define the knowledge, skills, and attitudes necessary to promote safety in a health care setting.
TOP: Assessment MSC: Safety and Infection Control
9. A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?
a. 55 years old
b. 20/20 vision
c. Urinary continence
d. Orthostatic hypotension
ANS: D
Numerous factors increase the risk of falls, including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, lower extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications (e.g., anticonvulsants, hypnotics, sedatives, certain analgesics).
DIF:Understand (comprehension)REF:375 | 388
OBJ: Describe assessment activities designed to identify a patient’s physical, psychosocial, and cognitive status as it pertains to his or her safety. TOP: Assessment
MSC: Safety and Infection Control
10. The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing?
a. Young infant
b. Toddler
c. Preschooler
d. Adolescent
ANS: B
The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and, because of their increased level of oral activity, put objects in their mouths. Young infant is too young. A preschooler and an adolescent are too old.
DIF:Understand (comprehension)REF:375-376
OBJ:Discuss the specific risks to safety related to developmental age.
TOP:AssessmentMSC:Health Promotion and Maintenance
11. A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session?
a. Proper fit of a bicycle helmet
b. Proper fit of soccer shin guards
c. Proper fit of swimming goggles
d. Proper fit of baseball sliding shorts
ANS: A
Head injuries are a major cause of death, with bicycle accidents being one of the major causes of such injuries. Proper fit of the helmet helps to decrease head injuries resulting from these bicycle accidents. Goggles, shin guards, and sliding shorts are important sports safety equipment and should fit properly, but they do not protect from this leading cause of death.
DIF:Apply (application)REF:376
OBJ:Discuss the specific risks to safety related to developmental age.
TOP: Teaching/Learning MSC: Health Promotion and Maintenance
12. The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?
a. Increased aggressiveness and blood spots on clothing may indicate substance abuse.
b. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing.
c. Adolescents need information about the effects of uncoordination on accidents.
d. Adolescents need to be reminded to use seat belts primarily on long trips.
ANS: A
Increased aggressiveness (psychosocial clue) and blood spots on clothing (environmental clue) may indicate substance abuse. School-age children are often uncoordinated. Seat belts should be used all the time. In fact, teens have the lowest rate of seat belt use.
DIF:Understand (comprehension)REF:376
OBJ:Discuss the specific risks to safety related to developmental age.
TOP: Teaching/Learning MSC: Health Promotion and Maintenance
13. The nurse is discussing about threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?
a. “Smoking even at parties is not good for my body.”
b. “Our campus is safe; we leave our dorms unlocked all the time.”
c. “As long as I have only two drinks, I can still be the designated driver.”
d. “I am young, so I can work nights and go to school with 2 hours’ sleep.”
ANS: A
Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and cardiovascular disease. It is prudent to secure belongings. When an individual has been determined to be the designated driver, that individual does not consume alcohol, beer, or wine. Sleep is important no matter the age of the individual and is important for rest and integration of learning.
DIF:Apply (application)REF:376 | 387
OBJ:Discuss the specific risks to safety related to developmental age.
TOP: Teaching/Learning MSC: Health Promotion and Maintenance
14. The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?
a. “Are you able to hear the tornado sirens in your area?”
b. “Are you able to read your favorite book?”
c. “Are you able to taste spices like before?”
d. “Are you able to open a jar of pickles?”
ANS: A
The ability to hear safety alerts and seek shelter is imperative to life safety. Decreased hearing acuity alters the ability to hear emergency vehicle sirens. Natural disasters such as floods, tsunamis, hurricanes, tornadoes, and wildfires are major causes of death and injury. Although age-related changes may cause a decrease in sight that affects reading, and although tasting is impaired and opening jars as arthritis sets in are important to patients and to those caring for them, being able to hear safety alerts is the most important.
DIF:Apply (application)REF:375
OBJ:Discuss the specific risks to safety related to developmental age.
TOP:AssessmentMSC:Health Promotion and Maintenance
15. The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint?
a. The patient refuses to call for help to go to the bathroom.
b. The patient continues to remove the nasogastric tube.
c. The patient gets confused regarding the time at night.
d. The patient does not sleep and continues to ask for items.
ANS: B
Patients who are confused, disoriented, and wander or repeatedly fall or try to remove medical devices (e.g., oxygen equipment, IV lines, or dressings) often require the temporary use of restraints to keep them safe. Restraints can be used to prevent interruption of therapy such as traction, IV infusions, NG tube feeding, or Foley catheterization. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.
DIF:Apply (application)REF:391
OBJ: Describe assessment activities designed to identify a patient’s physical, psychosocial,
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