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Potter & Perry: Fundamentals of Nursing, 7thEdition

Test Bank

Chapter 3: Client !afety

"#$T%P$E C'%CE

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

1. Bacterial contamination of foods is uncontrollable.

2. Fire is the greatest cause of unintentional death.3. Carbon dioide levels should be monitored in home settings.

!. Tem"erature etremes seldom affect the safety of clients in acute care facilities.

#$%& 3#nnual ins"ections of heating systems' chimneys' and a""liances should be done in

"rivate homes. Carbon monoide detectors are available but should not be used as a

re"lacement for "ro"er use and maintenance of fuel(burning a""liances. Bacterialcontamination of foods is controllable. The F)# is a federal agency res"onsible for the

enforcement of federal regulations regarding the manufacture' "rocessing' and

distribution of foods' drugs' and cosmetics to "rotect consumers against the sale ofim"ure or dangerous substances. *otor vehicle accidents are the leading cause of

unintentional death' not fire. Tem"erature etremes can affect the safety of clients in

acute care facilities' es"ecially the elderly.

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2. #n ambulatory client is admitted to the etended care facility with a diagnosis of

#lzheimer7s disease. ,n using a falls assessment tool' the nurse 8nows that the greatest

indicator of ris8 is&1. Confusion

2. ,m"aired 9udgment

3. %ensory deficits!. :istory of falls

#$%& !#ccording to the falls assessment tool' the greatest indicator of ris8 is a history of falls.

#ccording to the falls assessment tool' the second leading ris8 factor for falls is

confusion. #ccording to the falls assessment tool' im"aired 9udgment is the fourth leadingris8 factor for falls. #ccording to the falls assessment tool' sensory deficit is the fifth

leading ris8 factor for falls.

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*osby items and derived items < 2==>' 2== by *osby' ,nc.' an affiliate of lsevier ,nc.

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3. #n inservice "rogram is being offered in the hos"ital on bioterrorism and the res"onse of

the health care agency. )uring the "rogram' the mitigation "hase is described. The nurseis informed that this "hase includes&

1. )etermination of hazard vulnerability and the im"act of the emergency situation

2. %te"s ta8en to manage the effects of the event and an inventory of availableresources

3. %te"s ta8en by staff to triage victims

!. -estoration of essential services

#$%& 1

The mitigation "hase consists of the assessment "rocess to determine hazard vulnerability

for the hos"ital7s service area. This includes an identification of the 8inds of emergencysituations that are most li8ely to occur and their "robable im"act. )uring the

"re"aredness "hase' ste"s are ta8en to manage the effects of the event' and an inventoryof available resources is ta8en. )uring the res"onse "hase' ste"s are ta8en by staff totriage victims. )uring the recovery "hase' ste"s are ta8en to restore essential services.

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!. #n inservice "rogram is being offered in the hos"ital on bioterrorism and the res"onse of

the health care agency. #n im"ortant as"ect of the "rogram is the recognition of the signsand sym"toms of bacterial and viral infections. # "ractice drill is held and the nurse

recognizes that the clients admitted with "ossible anthra will demonstrate&1. #bdominal cram"ing' diarrhea' droo"ing eyelids' 9aw clench' and difficulty

swallowing

2. Fluli8e sym"toms' gastrointestinal distress' and "a"ular lesions

3. Fever' cough' chest "ain' and hemo"tysis!. @esicular s8in lesions on the face and etremities

#$%& 2Clinical features of anthra include fluli8e sym"toms' gastrointestinal distress' and

"a"ular lesions. #bdominal cram"ing' diarrhea' droo"ing eyelids' 9aw clench' anddifficulty swallowing are clinical features of botulism. Fever' cough' chest "ain' andhemo"tysis are characteristic of "lague. @esicular s8in lesions on the face and etremities

are seen with small"o.




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. # 1(year(old child is scheduled to receive an ,@ line. The most a""ro"riate ty"e of

restraint to use for this client to "revent removal of the ,@ line would be aAn&

1. rist restraint2. ac8et restraint

3. lbow restraint

!. *ummy restraint

#$%& !

# mummy restraint is used short(term for a small child or infant for eamination or

treatment involving the head and nec8. This would be the most a""ro"riate ty"e ofrestraint to use for a 1(year(old child who is going to receive an ,@ line. The wrist

restraint maintains immobility of an etremity to "revent the client from removing a

thera"eutic device' such as an ,@ tube. ,t would not be the best choice for starting an ,@on a 1(year(old child. The 9ac8et restraint is often used to "revent a client from getting u"

and falling. ,t is not the best choice for starting an ,@ line. #n elbow restraint iscommonly used with infants and children to "revent elbow fleion' such as after an ,@line is in "lace.


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D. # ;>(year(old resident in a long(term care facility is 8nown to Ewander at night and has

fallen in the "ast. hich of the following is the most a""ro"riate nursing intervention?1. #n abdominal restraint should be "laced on the client during slee"ing hours.

2. The client should be chec8ed freGuently during the night.3. # radio should be left "laying at the bedside to assist in reality orientation.

!. The client should be "laced in a room that is away from the activity of the nurses7

station.

#$%& 2

#lternatives to restraints should be attem"ted first. A# "hysician7s order is reGuired for

restraints to be a""lied. The most a""ro"riate intervention is to chec8 on the clientfreGuently. #lternatives to restraints should be attem"ted first before an abdominal

restraint while slee"ing.# radio may hel" orientate a client to reality. :owever' the most a""ro"riate interventionfor the client who wanders is to chec8 on the client freGuently. Clients who wander

should be assigned to rooms near the nurses7 station and chec8ed on freGuently.

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;. The wor8men cause an electrical fire when installing a new "iece of eGui"ment in theintensive care unit. # client is on a ventilator in the net room. The first action the nurse

should ta8e is to&

1. +ull the fire alarm2. #ttem"t to etinguish the fire

3. Call the "hysician to obtain orders to ta8e the client off the ventilator

!. Hse an #mbu(bag and remove the client from the area

#$%& !

,f there is a fire' and the client is on life su""ort' the nurse should maintain the client7s

res"iratory status manually with an #mbu(bag and move the client away from the fire.The first action of the nurse is not to "ull the fire alarm. The wor8men could do that. The

wor8man can attem"t to etinguish the fire. The nurse should attend to the client who is

closest to the fire in the net room. The nurse should not call the doctor to obtain ordersto ta8e the client off the ventilator because this will ta8e valuable time. The client needs

to be moved away from the fire' and the source of oygen needs to be discontinued' as itis combustible. The client will need to be manually resuscitated with an #mbu(bag.

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/. ,n a nursing home an elderly client dro"s his burning cigarette in a trash can and starts a

fire. The most a""ro"riate ty"e of fire etinguisher for the nurse to use is the&

1. Ty"e #

2. Ty"e B3. Ty"e C

!. Ty"e )

#$%& 1

Ty"e # fire etinguishers are used for ordinary combustibles such as wood' cloth' "a"er'

and "lastic. # trash can fire would reGuire a ty"e # fire etinguisher. Ty"e B fireetinguishers are used for flammable liGuids such as gasoline' grease' "aint' and

anesthetic gas. Ty"e C fire etinguishers are used for electrical eGui"ment. There is no

ty"e ) fire etinguisher.

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>. # visiting nurse com"letes an assessment of the ambulatory client in the home and

determines the nursing diagnosis of risk for injury related to decreased vision. Based on

this assessment' the client will benefit the most from&1. ,nstalling fluorescent lighting throughout the house

2. Becoming oriented to the "osition of the furniture and stairways

3. *aintaining com"lete bed rest in a hos"ital bed with side rails!. #""lying "hysical restraints

#$%& 20rienting the client to the "osition of furniture in the room and stairways is the best

intervention to hel" "revent falls for the client with decreased vision. #ttem"ts should be

made to reduce glare. ight bulbs that are D= watts or less may be increased to ; watts to

hel" im"rove visibility. The best intervention to "revent falls is to first orient the client tothe surroundings. *aintaining com"lete bed rest is not the best o"tion. Com"lete bed rest

can cause other health "roblems resulting from a lac8 of mobility. The client should not

be restrained for "oor vision. #ttem"ts should be made to hel" com"ensate for thedecreased vision in order to "revent falls.

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1=. hich one of the following statements by the "arent of a child indicates that further

teaching by the nurse is reGuired?1. E$ow that my child is 2 years old' , can let her sit in the front seat of the car with

me.

2. E, ma8e sure that my child wears a helmet when he rides his bicycle.

3. E, have s"o8en to my child about safe se "ractices.!. E*y child is ta8ing swimming classes at the community center.

#$%& 1

This statement indicates that further teaching is reGuired. Children weighing less than /=

"ounds or who are under / years of age should always be in an age5weight(a""ro"riate

car seat that has been installed according to manufacturer7s directions. ,n cars with a"assenger air bag' children under 12 should be in the bac8 seat. #nswer 2 is an

a""ro"riate safety measure to reduce in9uries from falling off a bi8e or being hit by a car.

#nswer 3 is an im"ortant safety measure because many adolescents begin seualrelationshi"s. #nswer ! is an a""ro"riate safety measure that may someday save a child7s

life.

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


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1. #n order for a restraint may be im"lemented indefinitely until it is no longer

reGuired by the client

2. -estraints may be ordered on an as(needed basis3. $o order or consent is necessary for restraints in long(term care facilities

!. -estraints are to be "eriodically removed to have the client reevaluated

#$%& !-estraints must be "eriodically removed' and the nurse must assess the client to

determine if the restraints continue to be needed. #nswer 1 is not a true statement. #"hysician7s order for restraints must have a limited time frame. ,f the orders are renewed'

it should be done so within a s"ecified time frame according to the agency7s "olicy.

-estraints are not to be ordered "rn Aas needed. The use of restraints must be "art of the

client7s medical treatment. #n order or consent is necessary for restraints in long(termcare facilities.

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12. 0n entering the client7s room' the nurse sees a fire burning in the trash can net to thebed. The nurse removes the client and calls in the fire. The net action of the nurse is to&

1. tinguish the fire

2. -emove all of the other clients from the unit3. Close all the doors of client rooms

!. *ove the trash can into the bathroom

#$%& 3The net action the nurse should ta8e is to confine the fire by closing doors and windows

and turning off oygen and electrical eGui"ment. The nurse should etinguish the fireusing an etinguisher after closing the doors of the client rooms. #fter activating the

alarm' the nurse should close all the doors' not remove all of the other clients from the

unit. #nswer ! would not be an a""ro"riate action because the nurse could get burned in

attem"ting to move the trash can.

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13. # mother of a young child enters the 8itchen and finds the child on the floor. There is a

bottle of cleanser net to the child and "articles of the substance around the child7s

mouth. The "arent7s first action should be to&1. Call the +oison Control unit

2. +rovide i"ecac syru"


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1D. The nurse should recognize which of the following clients as being at greatest ris8 for an

unintentional death?

1. # /(year(old who s8is regularly2. # !!(year(old alcoholic who lives alone

3. # ;2(year(old identified as at high ris8 for falls

!. # 3!(year(old diagnosed with chronic de"ression

#$%& 3

#mong older adults D years and older' falls are the leading cause of unintentional death.

hile the remaining o"tions reflect clients at ris8' the "robability is not as great.

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1;. hich of the following nursing interventions has the greatest li8elihood of minimizing

the ris8 of in9ury for a client who freGuently gets out of bed at night to go into the

bathroom?1. imiting fluid inta8e after D +*

2. ,lluminating the "athway to the bathroom

3. Toileting the client whenever awa8e at night!. Chec8ing on the client at least hourly during the night

#$%& 2

hile chec8ing on the client freGuently is not incorrect' night(lights in dar8 halls'bathrooms' and the rooms of children and older adults hel" maintain safety by reducing

the ris8 of falls. The remaining o"tions are more directed at controlling urinary out"utthan "reventing in9ury.

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1/. hen discussing the "revention of fire(related in9uries and deaths' the nurse should "lace

the greatest em"hasis on the&1. +revention role smo8e detectors "lay2. )angers of careless smo8ing habits

3. %u"ervision of children around o"en flames

!. ,m"ortance of readily accessible fire etinguishers

#$%& 2

The leading cause of fire(related death is careless smo8ing. hile the other o"tions

reflect ris8' they are not as highly "rioritized as the answer.


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1>. The nurse recognizes that the leading cause of death for the otherwise healthy 1(year(old

is&1. +hysical abuse

2. #ccidental in9ury

3. Contagious diseases

!. %tranger abduction

#$%& 2

,n9uries are the leading cause of death in children older than 1 year of age and cause moredeaths and disabilities than do all diseases combined.

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2=. The nurse is "re"aring a safety(related "rogram for a grou" of "arents of ( to 1!(year(

olds. hich of the following to"ics is most li8ely to "ositively im"act the leading causeof in9ury for this age(grou"?

1. EKee"ing them safe while they "lay s"orts

2. EBicycle riding with safety in mind

3. E%afety first when around water!. E)on7t let fire hurt your child

#$%& 2

Children to 1! years of age account for nearly one third of bicyclists 8illed in traffic

accidents. hile the remaining o"tions deal with ris8 factors' the "riority relates to

bicycle(oriented accidents.



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21. The nurse recognizes which of the following clients is at greatest ris8 for an accidental

death?

1. # D=(year(old who is a wee8end Ealcoholic2. # !=(year(old who is a "rofessional mountain climber

3. # 3(year(old who commutes 3 miles to wor8 each morning

!. # =(year(old who recently lost his 9ob because of a wor8(related in9ury


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#$%& !

The adult e"eriencing a high level of stress is more li8ely to have an accident or illness

such as headaches' gastrointestinal AL, disorders' and infections. hile the remainingo"tions identify ris8s' they are not a high as that of the stressed adult.

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22. # client who is e"eriencing a generalized clonic(tonic seizure is at greatest ris8 for

in9ury caused by&1. The "hysical colla"se that occurs at the onset of the seizure

2. *uscle strains that result from the severe muscle 9er8ing during the seizure

3. The tongue laceration that occurs from 9aw clenching during the seizure!. #s"iration resulting from the tem"orary loss of consciousness after the seizure

#$%& 1)uring a fall' or as a result of muscle 9er8ing' musculos8eletal in9uries can occur. The fall

is the most "roblematic since is occurs in the vast ma9ority of the seizure events.

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23. hich of the following clients is at greatest ris8 for in9ury related to medical diagnoses

and conditions?

1. # history of asthma and alcohol abuse2. # history of heart failure and urinary urgency

3. # history of hy"ertension and wearing corrective lenses!. # history of chronic bronchitis and im"aired hearing

#$%& 2

This client is li8ely using diuretics that increase the freGuency of voiding and result in theclient having to use toilet facilities more often. Falls often occur with clients who have to

get out of bed Guic8ly because of urinary urgency.

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2!. The nurse is conducting an admission interview and assessment on a cognitivelyim"aired' uncoo"erative client for the ris8 for in9ury. hich of the following o"tions will

most li8ely "rovide the information to confirm the diagnosis?

1. Base the degree of ris8 on observable data at the time of the client7s current hos"ital


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admission.

2. Closely monitor the client7s behavior and habits until ris8 for in9ury can be

reasonably determined.3. *a8e certain critically sound assum"tions are based on the client7s develo"mental

stage and current cognitive stasis.

!. ,nterview the client7s family' friends' and5or caregivers regarding "rehos"italizationris8 factors.

#$%& !,n many cases family members are im"ortant resources in assessing a client7s fall ris8.

Families often are able to re"ort on the client7s level of confusion and ability to ambulate.

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2. # nurse wor8ing in an acute care facility7s emergency de"artment should recognizewhich of the following client re"orts as being most sus"icious of a terrorist attac8?

1. Four deaths resulting from a "rivately owned air"lane crashing into a four(story

building

2. $umerous re"orts of res"iratory distress among older adults who attended anoutdoor musical event

3. 1 cases of nausea and vomiting re"orted over a 2(day "eriod when ! cases would

be within normal for the facility!. 1= children' all who attended a child(oriented arts and crafts fair' "resenting with

rashes on their hands and faces

#$%& 3#n unusual increase in the number of "eo"le see8ing care' es"ecially with fever'

res"iratory' or gastrointestinal com"laints' is a classic indicator of such an event. hilethe other o"tions "resent "ossible indicators' there are other "ossible reasons for the

incidents.

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2D. The nurse is discussing safety issues with the mother of three children. hich of thefollowing statements has the greatest "ossibility for decreasing the "otential for in9uryamong the children?

1. Ehere do you see a need for safety im"rovements in your home?

2. EKee" all toic liGuids ca""ed and stored out of reach of the children.

3. E,nstalling safety gates at the to" and bottom of each set of stairs will hel"minimize falls.

!. ETa8e great care to 8ee" the children away from 8itchen a""liances and tools that


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can hurt them.

#$%& 1Clients generally e"ect to be safe in their homes and health care settings. :owever' there

are times when a client7s view of what is safe does not agree with that of the nurse. For

this reason' any assessment needs to include the client7s understanding of his or her

"erce"tion of ris8 factors. The remaining o"tions are directed toward s"ecific safetyissues.

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2;. The nurse recognizes that the greatest benefit of engaging the mother of two smallchildren into a discussion about child("roofing her home is that&

1. The home will be safe for the immediate time being

2. ,f an accident occurs' it will li8ely be minor in nature3. %he is li8ely to monitor the house for safety issues in the future

!. %he will serve as a role model regarding safety issues for her children

#$%& 3The client who is an active "artici"ant in reducing threats to safety becomes more alert to

"otential hazards.

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2/. The nurse and a mother of two small children are discussing child safety issues. hich ofthe following nursing interventions has the greatest "otential for using collaboration to

hel" ensure the children7s safety?

1. #rranging to teach the children how to react in the case of a fire in the home

2. Teaching the children to tele"hone >11 if there is ever an emergency in the home3. :el"ing the mother identify an emergency "erson for the children to tele"hone in

the case of an emergency

!. :el"ing the mother create a list of emergency tele"hone numbers to be "osted netto the home7s tele"hone

#$%& !Clients need to learn how to identify and select resources within their community that

enhance safety Ae.g.' neighborhood bloc8 homes' local "olice de"artments' and neighbors

willing to chec8 on a client7s well(being.The remaining o"tions deal with individual

as"ects of a com"lete "lan.

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2>. hen "re"aring a safety wor8sho" for early teens A13 to 1 years old' the nurse

recognizes that which of the following active strategy to"ics has the greatest "otential for

decreasing in9uries in this "o"ulation by affecting lifestyle changes?1. #voiding the nicotine habit

2. Kee"ing immunizations u" to date

3. ating a well(balanced' low(fat diet!. earing a seat belt when riding in an automobile

#$%& !

To "romote an individual7s health' it is necessary for the individual to be in a safeenvironment and to "ractice a lifestyle that minimizes ris8 of in9ury. #ctive strategies are

those in which the individual is actively involved through changes in lifestyle Ae.g.'

wearing seat belts or installing outdoor lighting and "artici"ation in wellness "rograms.#ccidents involving automobiles account for the most substantial number of in9uries and

deaths among this "o"ulation from among the o"tions "rovided.

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3=. The nurse is discussing measures to minimize the ris8 of in9ury from an automobileaccident with an /3(year(old adult client who lives alone and claims to drive only to

church' the doctor7s office' and for groceries. hich of the following suggestions has the

greatest "otential for affecting this client7s safety?

1. Ta8e "ublic trans"ortation whenever it is available.2. +lan errands around church or doctor7s a""ointments.

3. +lan driving for short tri"s and only during the daylight hours.!. #rrange for family or friends to drive you whenever it is "ossible.

#$%& 3

The nurse educates clients regarding safe driving ti"s Ae.g.' driving shorter distances oronly in daylight' using side and rearview mirrors carefully' and loo8ing behind them

toward their Eblind s"ot before changing lanes. The other o"tions' while not incorrect'

may not be realistic or a""ealing to an inde"endent client.

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

1. #ngry' loud crying


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2. Hrinary incontinence

3. -eddened areas on wrists

!. :ands are cool to the touch

#$%& !

hile the use of any restraint may be associated with serious com"lications' including

"ressure ulcers' consti"ation' "neumonia' urinary and fecal incontinence' and urinaryretention' the most serious are contractures' nerve damage' and circulatory im"airment.

The coolness of the client7s hands indicates "oor circulation and can result in "ermanentdamage.

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32. The nurse is discussing a newly ordered diuretic with an older adult client who is home(

bound. hich of the following suggestions has the greatest "otential for minimizing theclient7s ris8 for in9ury related to urinary urgency or incontinence?

1. Consider decreasing fluid inta8e after D +*.

2. ,lluminate the "ath to the bathroom at night.

3. ncourage the client to urinate immediately before bed.!. ncourage the client to ta8e the medication early in the morning.

#$%& !$octuria and incontinence are more freGuent in older adults. Live diuretics in the

morning. hile the other o"tions may have value' they do not have an im"act on the

situation as directly as the administration of the medication.

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33. # nurse caring for an elderly client who has had surgery and is in the hos"ital 8nows thatthe client is at high ris8 for develo"ing a nosocomial infection. 0ne of the most im"ortant

things that the nurse can do to "revent this client from obtaining a nosocomial infection is

to&1. +ractice a""ro"riate hand hygiene

2. -eGuest "ro"hylactic antibiotics for the client3. +lace the client in isolation!. ncourage the client to turn' cough and dee" breath every 2 hours

#$%& 2


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Com"rehension

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3D. hen discussing the new mother7s "ending discharge from the hos"ital' the nurse

determines that additional client teaching needs to ta8e "lace because of which of the

following comments?1. *y husband has installed the new car seat in the middle of the bac8seat of our car.

2. , can7t wait to "ut my baby in her new crib with the ensemble that my mom madeN

sheets' blan8ets' and bum"er to match.

3. , need to "lace my baby on her bac8 to slee"' right?!. , have chec8ed all my baby7s toys to ma8e sure that they don7t contain lead "aint.

#$%& 2$ewborns should not be "laced in cribs with loose comforters' bum"er "ads' etc. The

middle of the bac8 seat is the safest "lace to "ut the infant car seat. Babies should not be"laced on their stomachs with their mouth and nose in close "roimity to the mattress'which is associated with sudden death syndrome. ead "aint on infant toys can lead to

brain damage.

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Com"rehension

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3;. # confused client on a ventilator was restrained to "revent him from "ulling out his

endotracheal tube. hich of the following could be a "ossible alternative measure thatthe nurse could use to avoid the use of the restraints?

1. 0rient the client to the environment and e"lain the need for the endotracheal tube.2. +rovide a trained sitter to continuously su"ervise the client.

3. Camouflage the endotracheal tube with stoc8inette dressing.

!. +romote relaation techniGues.

#$%& 2

# trained sitter can "revent the client from "ulling out the endotracheal tube. The client is

confused and does not understand. The endotracheal tube cannot be camouflagedeffectivelyOthe client feels it more than sees it. Because the client is confused' it may be

very difficult to communicate relaation techniGues so that the client has anunderstanding.

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3/. # confused client needs to have restraints to "revent him from "ulling out his Foley

catheter. hich of the following can the nurse delegate to the nursing assistive

"ersonnel?1. #""lying restraints

2. 0btaining a "hysician7s order to restrain the client

3. )ocument the events that led to restraining the client!. valuating the effectiveness of the restraints

#$%& 1#lthough the nursing assistive "ersonnel can a""ly the restraints under the nurse7s

direction' they cannot document' evaluate' or ta8e "hysician7s orders.

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3>. # nurse finds that an electrical cord has shorted out in a client7s room' causing a fire. Thenurse should do which of the following actions first?

1. #ctivate the alarm.

2. Confine the fire by closing the client7s door.

3. -emove the client from the room.!. tinguish the fire.

#$%& 3The mnemonic -#C should be used to hel" remember to rescue or remove all clients in

immediate danger' activate the alarm' confine the fire' and etinguish the fire


T0+& $ursing +rocess& #ssessment*%C& $C4 test "lan designation& %afe and ffective Care nvironment5%afety and

,nfection Control

!=. hich of the following statements indicates that the client is at ris8 for an electricalshoc8 at home?

1. E, had to cut off the third "rong on the electrical "lug so that it would fit in the

etension cord.2. E*y bread got stuc8 in my toaster this morning' and , un"lugged it before trying to

remove it.3. E, always read the owner7s manual when , "urchase a new electrical a""liance.!. E, always ma8e sure that , am standing in a dry area before o"erating electrical

eGui"ment.

#$%& 2The Ethird "rong is used to ground the "iece of eGui"ment. ,m"ro"erly grounded

eGui"ment can cause electrical in9ury.


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!1. The nurse is caring for a client with a history of e"ile"tic seizures. The nursing assistive"ersonnel notifies the nurse that the client is having a seizure. The first thing that the

nurse should do when arriving in the room is to&

1. -aise the bed side rails2. +ut the bed in the lowest "osition

3. +osition the client safely

!. +rovide "rivacy

#$%& 3

#lthough #nswers 1' 2 and 3 are all im"ortant safety interventions' the "riority is to

safely "osition the client. ,t is im"ortant to "rovide "rivacy' but safety interventions are a"riority.

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T0+& $ursing +rocess& ,m"lementation

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!2. # client with a history of e"ile"sy arrives in the emergency de"artment e"eriencing

status e"ile"ticus. The nurse should never do which of the following?1. )ocument seGuence of events' including any adverse outcomes.

2. +re"are to initiate ,@ access.

3. #ccess oygen and suctioning eGui"ment.

!. 0"en client7s mouth by "lacing fingers on 9aw and inserting thumb on bottom teethto "lace oral airway between seizures.

#$%& !

$urses should never "ut their fingers in or close to a clients mouth who is or has been

e"eriencing seizure activity' to "revent being bitten in the event that the client should

e"erience more seizure activity. The nurse is res"onsible for all of these measures in#nswers 1' 2' and 3 to "rovide for the safety of the client' as well as document the

seGuence of events including any une"ected outcomes.

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"#$T%P$E (E!P'N!E

1. The nurse caring for clients in an acute care facility recognizes that attending to the safety

of each client is most li8ely to result in& A%elect all that a""ly.


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1. Freedom from illness

2. # shorter hos"ital stay

3. #ttention to the basic human needs!. # well(founded sense of well(being

. +reservation of the o"timal functioning level

D. *inimal e"osure to bacterial cross(contamination#$%& 2' 3' !' ' D

%afety in health care settings reduces the incidence of illness and in9ury' "reventsetended length of treatment and5or hos"italization' im"roves or maintains a client7s

functional status' and increases the client7s sense of well(being. # safe environment gives

"rotection to the staff as well' allowing them to function at an o"timal level. # safe

environment includes meeting basic needs' reducing "hysical hazards' reducing thetransmission of "athogens' maintaining sanitation' and controlling "ollution. hile a

reduction of illness is an e"ectation' there is no assurance of the freedom from illness.

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Com"rehensionT0+& $ursing +rocess& +lanning


,nfection Control

2. The nurse recognizes that children living in older housing that may contain lead(based

"aints may ehibit which of the following signs and sym"toms? A%elect all that a""ly.

1. @omiting2. #noreia

3. :eadaches

!. Bloody urine

. Thoracic rashD. %wollen 9oints

#$%& 1' 2' 3

%igns and sym"toms of lead "oisoning ty"ically include im"aired hearing' vomiting'

headaches' a""etite loss' and learning and behavioral "roblems. The remaining o"tions

are not ty"ically seen with this condition.

+T%& 1 ),F& C -F& /!! 0B& #nalysis


,nfection Control

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Chapter 038

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