Chapter 13 Safety PDF

Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Chapter 13 Safety Multiple Choice Ide...

Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Chapter 13 Safety Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A nurse is caring for a female patient who has been hospitalized for a right-sided cerebrovascular accident (CVA). The patient is impulsive and confused. She has weakness on the left side of her body and requires assistance when ambulating. What is the nurse’s highest priority when caring for this patient? 1. Range-of-motion exercises 2. Calculating a calorie count 3. Ordering a social service consult 4. Ensuring that the bed alarm is turned on 2. A nurse manager is working on methods to decrease patient falls on the nursing unit. Which nursing action would lead to decreased falls? 1. Prompt answering of call bells 2. Medicating patients for pain 3. Use of restraints 4. One side rail up on patient beds 3. A nursing instructor supervises a student nurse who is caring for a patient who is on fall precautions. The nursing instructor would intervene if the student nurse is observed doing what? 1. Keeping the bed at the highest position at all times 2. Using furniture to block areas that are off limits to the patient 3. Placing the client’s bed at the lowest level when the patient is sleeping 4. Placing the overbed table across the wheelchair when the patient is seated 4. A nurse is admitting a 65-year-old patient with a diagnosis of transient ischemic attack. The patient is alert and responds appropriately to questions. Based on this information, what type of intervention should the nurse take to maintain patient safety? 1. Use restraints. 2. Initiate fall assessment protocol. 3. Use a bed alarm. 4. Maintain contact precautions. 5. A fire breaks out on the nursing unit and the fire doors close. A family member tries to open the doors. What is the best response by the nurse based on the RACE protocol? 1. Allow the family member to open up the door to get to the patient’s room. 2. Remove the family member from the area to prevent further danger. 3. Tell the family member to pull the fire alarm near the nurses’ station. 4. Tell the family member not to try to open the doors. 6. A nursing student is reviewing the PASS acronym. Which action is consistent with following this protocol? 1. Pull the alarm. 2. Ask for assistance. 3. Sweep the area with the nozzle. 4. Select proper equipment. 7. A charge nurse supervises an unlicensed assistive personnel (UAP) while providing care to a patient at risk for falls. The patient repeatedly attempts to get out of bed without assistance. The charge nurse intervenes when observing which action by the UAP? 1. Placing the patient’s mattress on the floor ______________________________________________________________________________________________ 191 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 2. Having the patient fold washcloths and towels 3. Having the patient sit in a rocking chair near the nurses’ station 4. Offering infrequent opportunities for the patient to go to the bathroom 8. A nurse is completing documentation on a chart outside the patient’s room and hears a loud thud coming from the room. What is the priority nursing action? 1. Complete charting, then return to the room. 2. Log out of computer and return to the room. 3. Call for assistance and complete charting. 4. Call out to the patient and ask if they are okay. 9. When caring for a patient with bilateral wrist restraints, a nurse can delegate which of the following to a certified nursing assistant (CNA)? 1. Educating the patient on restraint alternatives 2. Checks and releases of the restraints 3. Assessment of bilateral radial pulses 4. Teaching of when restraints can be removed 10. A nurse is working on a nursing unit and moving a patient up in the bed. Which observation by the nurse manager warrants immediate intervention? 1. The nurse uses a draw sheet to help move the patient. 2. The nurse lowers the head of the bed. 3. The nurse asks the patient to cross arms around chest. 4. The patient’s bed is in the lowest position. 11. A nurse is extinguishing a fire that has broken out in the workplace. Which is the first step the nurse should take? 1. Squeeze the handles together. 2. Pull the pin found between the handles. 3. Aim the nozzle at the base of the flames. 4. Sweep the nozzle back and forth at the base of the flames. 12. A nurse is monitoring a chemotherapy patient and finds a moderate amount of fluid on the floor in the patient’s room. The nurse is not sure about what the fluid is. What is the priority nursing action? 1. Remove the patient from the room. 2. Secure area and prevent contamination. 3. Dilute with water. 4. Contact housekeeping for removal. 13. A student nurse encounters an unresponsive patient in a waiting room. The patient is not breathing and has no pulse or respirations. What is the first step the student nurse should take? 1. Begin rescue breathing. 2. Alert the emergency team. 3. Begin cardiopulmonary resuscitation (CPR). 4. Perform the Heimlich maneuver. 14. A member of the hospital maintenance staff is mopping the floor when patients begin to complain about watery eyes and irritated throats. Which priority action should the nurse take? 1. Evacuate the area immediately. 2. Notify the Centers for Disease Control and Prevention (CDC). 3. Treat the patient for chemical exposure. 4. Identify the chemicals and consult the safety data sheets (SDSs). ______________________________________________________________________________________________ 192 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 15. A patient who is a fall risk is sitting in the chair with the call bell in reach after being assisted by the certified nursing assistant (CNA). The patient’s bed alarm continues to go off. What is the first action that the nurse should take upon going into the patient’s room? 1. Talk to the CNA. 2. Ask the patient if they are okay. 3. Obtain vital signs. 4. Turn the alarm off. Multiple Response Identify one or more choices that best complete the statement or answer the question. 16. Which of the following items increase a patient’s risk for falling, according to the Morse Fall Scale? Select all that apply. 1. History of falls within the last 2 years 2. Use of a cane 3. Has an IV/saline lock 4. Requires nurse-assisted ambulation 5. Has altered mental status 17. A nurse is caring for a patient who has been placed in restraints. Which statements made to the patient by the nurse indicate an understanding of following restraint guidelines of the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission? Select all that apply. 1. “Would you like some water?” 2. “I’ll check on you every 3 hours.” 3. “Do you need help going to the bathroom?” 4. “Let’s change the position you’re lying in.” 5. “We’ll remove these in about an hour.” 18. A nurse is assessing a patient using the Morse Fall Scale and documents a modified risk level II. Which findings best support this assessment? Select all that apply. 1. Patient uses an assistive device to ambulate. 2. Patient score is above 70. 3. Patient has several comorbidities. 4. Patient has fallen at home recently. 5. Patient is NPO. 19. A nurse is monitoring a patient who continually attempts to scratch an area of the body. Which priority actions should the nurse take to minimize this patient action? Select all that apply. 1. Apply a vest restraint. 2. Apply mitt restraint bilaterally. 3. Contact the health-care provider (HCP) for an order. 4. Keep call bell in reach. 5. Secure restraint to the bed rail. 20. A nurse is monitoring a patient who has received implanted radiation therapy. What are the best nursing actions related to taking care of this type of patient? 1. Wear a film badge. 2. Make frequent in-room checks. 3. Follow hospital policy and protocols. 4. Dispose of bodily fluids per protocol. 5. Maintain reverse isolation. ______________________________________________________________________________________________ 193 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 21. A group of student nurses are reviewing what to do should a mass casualty event (MCE) occur while they are in the clinical environment. Which actions should the student nurses be expected to perform? Select all that apply. 1. Participate per designated role according to hospital policy and procedure. 2. Go home immediately. 3. Secure a safe environment if possible. 4. Call family. 5. Attend to immediate safety. 22. A nurse is working on a medical unit where restraints have been routinely used on patients to prevent them from injury. For which situations would the use of restraints be indicated? Select all that apply. 1. A patient who is yelling all the time 2. A patient who is using the call bell repeatedly 3. A patient who is confused and combative 4. A patient who keeps pulling on urinary catheter 5. A patient who has fallen and is cognitively impaired 23. A nurse is documenting the Morse Fall Scale for a patient who is admitted for urinary sepsis, has no other comorbidities, uses a walker, is receiving IV antibiotics, has a weak gait, and is oriented to time and place. What information should the nurse document? Select all that apply. 1. Level III fall risk 2. Requires a bed check device 3. Can transfer with minimal assistance 4. Needs a referral for social services upon discharge 5. Requires modified fall interventions 24. A nurse applies wrist restraints to a patient. Which actions indicate appropriate technique? Select all that apply. 1. Mitt secured around wrist of patient 2. Straps attached to bed rail 3. Must be applied bilaterally 4. Check area every 2 hours 5. Strap secured to patient’s waist Other 25. A nurse is working at a clinic when an electrical fire begins. Place the steps the nurse should take in the appropriate order. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234.) 1. Sound the fire alarm. 2. Extinguish the fire. 3. Evacuate all clients from the area. 4. Close all doors in the immediate area. ______________________________________________________________________________________________ 194 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Chapter 13 Safety Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter: Chapter 13, Safety Objective: 3. Describe six factors that contribute to an unsafe patient environment. Page: 197 Heading: Safe Environment for Patients > Factors Contributing to an Unsafe Patient Environment Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. Safety should be foremost in the nurse’s mind when caring for any patient. Range-of-motion exercises are generally appropriate for this type of patient, but they do not address patient safety. 2 This is incorrect. Safety should be foremost in the nurse’s mind when caring for any patient. There is no indication that the patient requires a calorie count. 3 This is incorrect. Safety should be foremost in the nurse’s mind when caring for any patient. Although ordering a social service consult is a good idea to facilitate discharge planning, ensuring patient safety is a higher priority. 4 This is correct. Safety should be foremost in the nurse’s mind when caring for any patient. Ensuring that the bed alarm is turned on helps to ensure patient safety. PTS: 1 CON: Safety 2. ANS: 1 Chapter: Chapter 13, Safety Objective: 4. Discuss strategies for preventing falls, including assessment rating scales and restraint alternatives. Page: 198 Heading: Factors Contributing to an Unsafe Patient Environment > Delayed Assistance Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 Feedback This is correct. It is imperative that call lights be answered promptly and that assistance be quickly available to maintain a safe environment for patients. Although poor staffing patterns may contribute to delayed assistance for patients, nursing staff must make rapid response to requests for assistance a high priority. This is incorrect. Medicating patients for pain does not directly prevent patient falls. This is incorrect. Use of restraints requires a physician’s order/nursing judgment in the context of an emergent patient situation. Restraints cannot be arbitrarily applied in the clinical setting. ______________________________________________________________________________________________ 195 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 4 This is incorrect. Keeping one side rail up is an example of a restraint. Use of restraints requires a physician’s order/nursing judgment in the context of an emergent patient situation. Restraints cannot be arbitrarily applied in the clinical setting. PTS: 1 CON: Safety 3. ANS: 1 Chapter: Chapter 13, Safety Objective: 4. Discuss strategies for preventing falls, including assessment rating scales and restraint alternatives. Page: 198 Heading: Safe Environment for Patients > Promoting Patient Safety Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 4 Feedback This is correct. The nurse should intervene. A patient’s bed should be kept at the lowest level at all times except when the nursing staff is at the bedside. This is incorrect. There is no need for the nurse to intervene. Furniture or equipment can be used to block areas that are off limits to the patient so that the patient remains in a safe zone. This is incorrect. The nurse does not need to intervene. A patient’s bed should be kept at the lowest level at all times except when the nursing staff is at the bedside. This is incorrect. No intervention is necessary. The overbed table can be placed across the wheelchair like a tray to help the patient remain seated in the chair. PTS: 1 CON: Safety 4. ANS: 2 Chapter: Chapter 13, Safety Objective: 4. Discuss strategies for preventing falls, including assessment rating scales and restraint alternatives. Page: 198 Heading: Preventing Falls > Fall Assessment Rating Scales Integrated Processes: Clinical Problem-Solving Process: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate 1 2 3 4 Feedback This is incorrect. There is no clinical indication to use restraints for this patient. This is correct. Because the patient is being admitted with a clinical diagnosis of TIA, the patient should be assessed for potential fall risk and protocols initiated based on findings if warranted. This is incorrect. There is no clinical indication to use a bed alarm at this time for this patient. This is incorrect. There is no indication to implement contact precautions for this patient. ______________________________________________________________________________________________ 196 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ PTS: 1 CON: Safety 5. ANS: 4 Chapter: Chapter 13, Safety Objective: 6. Explain the acronyms RACE and PASS. Page: 202 Heading: Responding to a Fire Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 4 Feedback This is incorrect. RACE acronym relates to confine, and this refers to doors closing per hospital policy. Do not allow the family member to open the door. This is incorrect. There is no indication that the family member is in imminent danger; therefore, this action is not warranted. This is incorrect. Because the fire doors have closed, activation of the system has been initiated. This action is not warranted. This is correct. RACE acronym relates to confine, and this refers to doors closing per hospital policy. The area is confined to maintain safety. PTS: 1 CON: Safety 6. ANS: 3 Chapter: Chapter 13, Safety Objective: 6. Explain the acronyms RACE and PASS. Page: 204 Heading: Responding to a Fire Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. PASS acronym is used to put out small fires with a fire extinguisher. P = Pull the pin found between the handles. A = Aim the nozzle of the fire extinguisher at the base of the flames. S = Squeeze the handles together to release the contents of the extinguisher. S = Sweep the nozzle back and forth at the base of the flames to extinguish the fire. 2 This is incorrect. PASS acronym is used to put out small fires with a fire extinguisher. P = Pull the pin found between the handles. A = Aim the nozzle of the fire extinguisher at the base of the flames. S = Squeeze the handles together to release the contents of the extinguisher. S = Sweep the nozzle back and forth at the base of the flames to extinguish the fire. 3 This is correct. Sweeping the nozzle back and forth at the base of the flames to extinguish the fire is part of the PASS system. 4 This is incorrect. The closest fire extinguisher is used in the PASS system. PTS: 1 CON: Safety ______________________________________________________________________________________________ 197 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 7. ANS: 4 Chapter: Chapter 13, Safety Objective: 4. Discuss strategies for preventing falls, including assessment rating scales and restraint alternatives. Page: 200 Heading: Safe Environment for Patients > Promoting Patient Safety > Stategies Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 4 Feedback This is incorrect. There is no need for the nurse to intervene. If there is a recurrent problem where the patient is unsafe due to repeated attempts to get out of bed, the mattress may be placed on the floor to prevent injury to the patient. This is incorrect. The nurse does not need to intervene. Patients who are at risk for falls can be given simple but purposeful activities to do, such as folding washcloths or towels. This is incorrect. No intervention is necessary. Some patients who are at risk for falls seem to have lots of energy and are looking for ways to stay busy. It can be helpful to have them sit in a rocking chair near the nurses’ station; often the motion of rocking helps them relax as well as use pent-up energy. This is correct. The nurse should intervene. Patients who are at risk for falls should be offered regular opportunities to go to the bathroom, have a snack, or have something to drink. Sometimes patients are attempting to do one of these things when they get out of bed unsafely. PTS: 1 CON: Safety 8. ANS: 2 Chapter: Chapter 13, Safety Objective: 16. Discuss information found in the Connection features in this chapter. Page: 200 Heading: Clinical Judgment in Action Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. The priority action is to determine if the patient is safe. Completion of charting can be done later. 2 This is correct. This is the correct nursing action because it maintains confidentiality in securing the patient’s chart and allows for immediate access to the patient’s room for assessment. 3 This is incorrect. Calling for assistance may be necessary once the nursing assessment has been performed. 4 This is incorrect. The nurse should not call out to the patient but re-enter the room and provide a complete assessment. ______________________________________________________________________________________________ 198 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ PTS: 1 CON: Safety 9. ANS: 2 Chapter: Chapter 13, Safety Objective: 5. Identify requirements for use of restraints and release of restraints. | 16. Discuss information found in the Connection features in this chapter. Page: 202 Heading: Supervision/Delegation Connection > Delegation of Wrist Restraints and Releases Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Leadership and Management Difficulty: Difficult 1 2 3 4 Feedback This is incorrect. The nurse cannot delegate patient education because the CNA cannot educate. This is correct. When a patient has restraints applied, the nurse can delegate the checks and releases to a CNA or unlicensed assistive personnel (UAP). This is incorrect. The nurse, not the CNA, should provide assessment. This is incorrect. When a patient has restraints applied, the nurse can delegate the checks and releases to a CNA or unlicensed assistive personnel (UAP). The CNA cannot teach or educate patients. PTS: 1 CON: Leadership and Management 10. ANS: 4 Chapter: Chapter 13, Safety Objective: 10. Identify ways to use body mechanics to prevent injury when caring for patients. Page: 206-207 Heading: Safe Environment for Nursing Staff > Minimizing Physical Hazards Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Mobility |Safety Difficulty: Moderate 1 2 3 4 Feedback This is incorrect. A draw sheet can be used to facilitate patient movement in the bed and will help decrease stress and strain to the nurse moving the patient. This is incorrect. Placing the head of the bed down will facilitate patient movement in the bed and will decrease stress and strain to the nurse moving the patient. This is incorrect. Asking the patient to cross arms across the chest will facilitate patient movement in the bed and decrease stress and strain to the nurse moving the patient. This is correct. Having the bed in the lowest position will place stress and strain on the nurse’s body because it constitutes poor body mechanics. PTS: 1 CON: Mobility |Safety 11. ANS: 2 Chapter: Chapter 13, Safety Objective: 6. Explain the acronyms RACE and PASS. | 16. Discuss information found in the Connection features in this chapter. ______________________________________________________________________________________________ 199 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Page: 204 Heading: Responding to a Fire Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 This is incorrect. The nurse should remember the acronym PASS. The first S refers to squeezing the handles together. 2 This is correct. The nurse should remember the acronym PASS. The P, or first step, notes that the nurse should pull the pin found between the handles. 3 This is incorrect. The nurse should remember the acronym PASS. The second step (A) notes that the nozzle of the fire extinguisher should be aimed toward the base of the flames. 4 This is incorrect. The nurse should remember the acronym PASS. The second S, or last step, notes that the nurse should sweep the nozzle back and forth at the base of the flames. PTS: 1 CON: Safety 12. ANS: 2 Chapter: Chapter 13, Safety Objective: 13. Discuss safe handling of chemicals and gases. Page: 208 Heading: Chemical Hazards Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 4 Feedback This is incorrect. There is no immediate need to remove the patient from the room because the patient is an oncology patient receiving chemotherapy treatment and is likely to be immunosuppressed. This is correct. The nurse should secure the area and prevent contamination and then initiate protocol relative to a potential chemical spill. This is incorrect. Because the nurse does not know what type of fluid this is, it would be prudent to obtain the safety data sheet (SDS) to determine which cause of action should be taken. This is incorrect. Because this may be a chemical spill, the appropriate action for disposal would relate to obtaining the safety data sheet (SDS) information once the area is secured. PTS: 1 CON: Safety 13. ANS: 2 Chapter: Chapter 13, Safety Objective: 8. Determine actions to take when a patient is unresponsive. Page: 204-205 Heading: Responding to Individual Emergencies ______________________________________________________________________________________________ 200 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 4 Feedback This is incorrect. Once a nurse has called the code, CPR or rescue breathing (breathing for the patient in case of respiratory arrest when the pulse is still palpable) should begin as appropriate. The nurse will continue efforts until the code team, a group of specially trained personnel designated to respond to codes throughout the hospital, arrives. This is correct. If a student comes upon a patient who is unresponsive, the emergency team should be alerted by the designated protocol system such as a code blue. This is incorrect. Once a nurse has called the code, CPR or rescue breathing (breathing for the patient in case of respiratory arrest when the pulse is still palpable) should begin as appropriate. The nurse will continue efforts until the code team, a group of specially trained personnel designated to respond to codes throughout the hospital, arrives. This is incorrect. CPR courses also include instruction and practice on the Heimlich maneuver, an action to relieve choking by thrusting just below a person’s xiphoid process. PTS: 1 CON: Safety 14. ANS: 4 Chapter: Chapter 13, Safety Objective: 13. Discuss safe handling of chemicals and gases. | 18. Identify specific safety features. Page: 208 Heading: Chemical Hazards Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 4 Feedback This is incorrect. Even cleaning supplies can pose hazards, especially if they spill or mix. The nurse first needs to determine what chemicals are being used to clean. This is incorrect. The CDC, a federal agency involved in protecting patients and staff from the spread of disease, has developed guidelines to reduce the risk of injury due to chemical exposure, but the nurse does not need to notify them just yet. This is incorrect. Before the nurse will know what actions should be taken, the nurse should first identify what chemicals are being used. This is correct. Anytime chemicals are used, the nurse should be aware of the hazards involved. Facilities are required to have SDSs on file for every chemical. An SDS contains information about potential harm caused by exposure and directions for what to do if the product comes in contact with skin, eyes, or mouth. PTS: 1 CON: Safety 15. ANS: 4 Chapter: Chapter 13, Safety ______________________________________________________________________________________________ 201 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Objective: 12. Describe ways to protect yourself from radiation hazards. | 17. Identify specific safety information. Page: 208-209 Heading: Nursing Care Plan for Patients at Risk for Falls Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate 1 2 3 4 Feedback This is incorrect. The nurse may well have to talk to the CNA about the importance of turning off the bed alarm prior to moving the patient to prevent it from continuing to go off, but it is not the priority at this time. This is incorrect. The patient is sitting in a chair after being assisted in transfer. The bed alarm relates to the patient not being in the bed. The nurse should not assume that there is a patient problem at this time. This is incorrect. There is no immediate need to obtain vital signs based on the provided information. This is correct. It is important to turn off the bed alarm prior to moving the patient because the continued alarm going off can be distracting. PTS: 1 CON: Safety MULTIPLE RESPONSE 16. ANS: 2, 3, 4, 5 Chapter: Chapter 13, Safety Objective: 4. Discuss strategies for preventing falls, including assessment rating scales and restraint alternatives. Page: 198 Heading: Preventing Falls > Fall Assessment Rating Scales Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 4 5 Feedback This is incorrect. A history of falls that is immediate or within the last 3 months increases the patient’s risk for falling. This is correct. A patient who uses a cane or walker is at higher risk of falling. This is correct. A patient with an IV/saline lock is at higher risk of falling. This is correct. Patients who require assistance with ambulation are at higher risk for falling. This is correct. A patient who has an altered mental status or forgets their own limitations is at higher risk for falling. PTS: 1 CON: Safety ______________________________________________________________________________________________ 202 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 17. ANS: 1, 3, 4, 5 Chapter: Chapter 13, Safety Objective: 5. Identify requirements for use of restraints and release of restraints. Page: 201 Heading: Safe Environment for Patients > Promoting Patient Safety > Restraints Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate 1 2 3 4 5 Feedback This is correct. When an order has been obtained and the restraints are in place, nursing staff is required by the CMS and The Joint Commission to offer fluids to the patient. This is incorrect. When an order has been obtained and the restraints are in place, nursing staff is required by the CMS and The Joint Commission to check on the patient every 30 minutes and assess the patient’s extremities for edema, capillary refill time, sensation, and function. This is correct. When an order has been obtained and the restraints are in place, nursing staff is required by the CMS and The Joint Commission to assist the patient with toileting as needed. This is correct. When an order has been obtained and the restraints are in place, nursing staff is required by the CMS and The Joint Commission to change the patient’s position in bed. This is correct. When an order has been obtained and the restraints are in place, nursing staff is required by the CMS and The Joint Commission to remove the restraints every 2 hours. PTS: 1 CON: Safety 18. ANS: 1, 3, 4 Chapter: Chapter 13, Safety Objective: 17. Identify specific safety information. Page: 199 Heading: Table 13.1 Morse Fall Scale Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 Feedback This is correct. Modified risk interventions are required for a level II assessment (score 25 to 50). Use of an assistive device would indicate a score of 15 points and is pertinent to this assessment. This is incorrect. The patient being aware of surroundings indicates no cognitive deficits and would be considered a normal finding, thus not contributing to the Morse Fall Score parameters. This is correct. Modified risk interventions are required for a level II assessment (score 25 to 50). Having a secondary diagnosis would indicate a score of 15 points and is pertinent to this assessment. ______________________________________________________________________________________________ 203 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 4 5 This is correct. Modified risk interventions are required for a level II assessment (score 25 to 50). A recent fall would indicate a score of 25 points and is pertinent to this assessment. This is incorrect. The patient’s intake status does not contribute directly to the Morse Fall Scale parameters. PTS: 1 CON: Safety 19. ANS: 2, 3, 4 Chapter: Chapter 13, Safety Objective: 5. Identify requirements for use of restraints and release of restraints. Page: 202-203 Heading: Table 13.2 Types of Physical Restraints Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 4 5 Feedback This is incorrect. There is no need to apply a vest restraint because it is used to protect a patient in danger of getting out of bed or out of a wheelchair or chair. This is correct. Bilateral mitts can be applied because they can be used to prevent scratching in patients with severe skin disorders. This is correct. The nurse should contact the HCP to obtain an order for restraints based on hospital policy and protocol. This is correct. It is important to keep the call bell in reach for a patient who has a restraint applied to ensure that they are able to communicate with the health-care staff. This is incorrect. Restraints should be secured to the moveable part of the bed frame, not the bed rails, because this can lead to a potentially serious consequence. PTS: 1 CON: Safety 20. ANS: 1, 3, 4, 5 Chapter: Chapter 13, Safety Objective: 12. Describe ways to protect yourself from radiation hazards. Page: 208 Heading: Radiation Hazards Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 Feedback This is correct. A nurse taking care of a patient who has implanted radiation should wear a film badge that records exposure over time. This is incorrect. For patients who have received radiation therapy, the nurse should limit the amount of time spent in the room to avoid exposure. This is correct. It is important for the nurse to follow hospital policy and procedure related to care of the patient who has implanted radiation. ______________________________________________________________________________________________ 204 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 4 5 This is correct. It is important to dispose of bodily fluids per protocol for the patient who has implanted radiation. This is correct. Reverse isolation is for patients who are immunocompromised. PTS: 1 CON: Safety 21. ANS: 1, 3, 5 Chapter: Chapter 13, Safety Objective: 9. Discuss the roles of nurses in a mass casualty event. Page: 205 Heading: Responding to Disasters Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 3 4 5 Feedback This is correct. If the MCE occurs while students are in the clinical environment, they should assume roles as designated by the hospital’s policy and procedure. This is incorrect. If the MCE occurs while students are in the clinical environment, it may not be safe for them to leave and/or they may not be able to leave. This is correct. If the MCE occurs while students are in the clinical environment, they should secure a safe environment if at all possible. This is incorrect. The primary responsibility when in the midst of the MCE is to maintain safety. Phone calls to family members may eventually take place, but they are not the priority. This is correct. If the MCE occurs while students are in the clinical environment, they should attend to their immediate safety. PTS: 1 CON: Safety 22. ANS: 3, 4, 5 Chapter: Chapter 13, Safety Objective: 4. Discuss strategies for preventing falls, including assessment rating scales and restraint alternatives. Page: 202 Heading: Restraints > Application of Restraints Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult 1 2 Feedback This is incorrect. Restraints should not be applied to a patient who is yelling. Other therapeutic measures to calm the patient should be used. This is incorrect. Restraints should not be applied to a patient who continually uses the call bell. The nurse should assess and evaluate why the patient is continuing to use the call bell and use other therapeutic measures to ensure adequate communication. ______________________________________________________________________________________________ 205 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 3 4 5 This is correct. Restraints can be used to care for a confused and combative patient to help maintain safety. This is correct. Restraints can be used to care for a patient who attempts to pull out a urinary catheter. This is correct. Restraints can be used for a cognitively impaired patient who has recently fallen. PTS: 1 CON: Safety 23. ANS: 1, 2 Chapter: Chapter 13, Safety Objective: 4. Discuss strategies for preventing falls, including assessment rating scales and restraint alternatives. Page: 198-199 Heading: Preventing Falls > Fall Assessment Rating Scales Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Clinical Judgment | Communication | Safety Difficulty: Difficult 1 2 3 4 5 Feedback This is correct. Based on the provided information, this patient would be categorized as a level III fall risk (above 51) with a score of 70 based on history of falling, using a walker, receiving IV antibiotic therapy, and having a weak gait. This is correct. This patient requires an assistive device to maintain patient safety due to increased fall risk. This is incorrect. This patient requires assistance upon transfer and/or ambulation. This is incorrect. There is insufficient information to contact social services for this patient at this time. This is incorrect. Modified fall interventions are for patients who are categorized as level II fall risk (between 25 and 50). PTS: 1 CON: Clinical Judgment | Communication | Safety 24. ANS: 1, 4 Chapter: Chapter 13, Safety Objective: 4. Discuss strategies for preventing falls, including assessment rating scales and restraint alternatives. Page: 202-203 Heading: Table 13.2 Types of Physical Restraints Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Clinical Judgment |Safety Difficulty: Difficult Feedback ______________________________________________________________________________________________ 206 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 1 2 3 4 5 This is correct. The patient’s hand is placed in the mitt, and the mitt is secured around the wrist. This is incorrect. Restraints should never be applied to the bed rail. This is incorrect. Bilateral application is not needed unless there is clinical indication. This is correct. All restraints should be checked every 2 hours. This is incorrect. Mitt restraints should not be secured to the patient’s waist. PTS: 1 CON: Clinical Judgment |Safety ORDER 25. ANS: 3142 Chapter: Chapter 13, Safety Objective: 6. Explain the acronyms RACE and PASS. | 16. Discuss information found in the Connection features in this chapter. Page: 204 Heading: Responding to a Fire Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback: The acronym RACE stands for rescue, alarm, confine, and extinguish. The nurse should first evacuate all patients. The nurse should then sound the fire alarm. The fire should then be confined by closing doors to the area where the fire is. Then, the nurse should extinguish the fire. PTS: 1 CON: Safety ______________________________________________________________________________________________ 207 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year?