Question 1

When assessing a patient,a nurse notes that the skin distal to a restraint is pale and cool to the touch.Which of the following interventions will the nurse perform first?

Accepted Answer

If a patient has altered neurovascular status of an extremity,such as cyanosis,pallor and coldness of skin,or complaints of tingling,pain,or numbness,remove the restraint immediately,and notify the physician.Loosening the restraint may not effectively restore adequate circulation.An improperly sized restraint may not provide the protection needed for the patient.

Question 2

Continuous seizure activity that lasts longer than 30 minutes is known as _______________.

Accepted Answer

Status epilepticus is a condition in which a person has a continuous seizure that lasts longer than 30 minutes.

Question 3

A nurse enters the room of a patient who is sitting in a chair and the patient begins to have a seizure.To promote patient safety,which nursing intervention will the nurse initially perform?

Accepted Answer

Assisting the patient to the floor is the initial intervention to prevent injury from falling out of the chair during the seizure.

Question 4

The patient is an older person who is admitted for a medical problem.While doing his admission assessment,the nurse learns that the patient gets up two to three times a night to use the restroom.The institution has only beds with four side rails.Which of the following is the appropriate rationale for leaving one of the lower side rails down?

Accepted Answer

Having all side rails raised can create a sense of confinement and may lead to patients attempting to climb over them, increasing the risk of falls. Leaving one lower side rail down allows easier access for the patient to get out of bed safely.

Question 5

To promote patient safety,government standards regarding mechanical and physical restraints state that

Accepted Answer

Government standards regarding mechanical and physical restraints require that alternative measures must be tried and implemented before restraints are used. Restraints should only be used as a last resort and in situations where there is a significant risk of harm to the patient, themselves, or others. The nurse's judgment alone is not sufficient for deciding to use restraints, and they should not be used to punish patients or to convenience staff. Restraints should be used only as a temporary measure and regularly assessed to determine if they are still necessary.

Question 6

As part of an attempt to implement a restraint-free environment,the nurse

Accepted Answer

Covering or camouflaging tubes and drains can help reduce the temptation for patients to pull on them, which can lead to injury and the need for restraints. Providing constant activity for the patient may not always be feasible or appropriate, changing caregivers too often can be disruptive for the patient and reduce continuity of care, and reducing visiting hours and therapy can limit social interaction and necessary medical interventions.

Question 7

When applying a belt restraint to a patient,it is important for the nurse to

Accepted Answer

Have the patient in a sitting position.Remove wrinkles or creases in clothing.Bring ties through slots in a belt.Apply a belt over clothes,gown,or pajamas to prevent damage to the skin.Make sure to place the restraint at the waist,not at the chest or abdomen.Avoid applying the belt too tightly.

Question 8

Health care facilities must provide employees with access to information about the properties of particular chemicals and information for handling substances in a safe manner.Facilities do this by providing ______________.

Accepted Answer

Safety data sheets (SDS) are documents that provide information on the properties of chemicals, including handling and safety measures, which is essential for employee safety in health care facilities.

Question 9

The patient is admitted to the hospital with prescriptions for activity as tolerated.He is wheelchair bound at home and has brought his own electric wheelchair and battery charger to help him maintain mobility.The nurse realizes that

Accepted Answer

The charger needs to be checked by hospital engineers to ensure it meets safety standards and does not pose a risk of electrical hazards in the hospital environment.

Question 10

After recognizing that a patient has received an electrical shock and removing the source of the shock,what should the nurse do next?

Accepted Answer

The nurse should first assess for the presence of a pulse to determine the patient's condition and the appropriate next steps, such as whether CPR is needed.

Question 11

When caring for a patient who has an arm or leg restraint in place,how often will the nurse remove the restraint?

Accepted Answer

The nurse should remove the restraint every 2 hours to assess the patient's comfort, circulation, and skin integrity, as well as to provide range-of-motion exercises and promote the patient's independence. Removing the restraint every 15-30 minutes would be too frequent and disruptive to the patient's care, while removing it only once a day would not be frequently enough to address potential issues.

Question 12

On entering the patient's room,the nurse sees a fire burning in the trashcan next to the bed.The nurse removes the patient and reports the fire.What is the nurse's next action?

Accepted Answer

The nurse should close all doors of patient rooms to contain the fire and prevent it from spreading, following the RACE protocol (Rescue, Alarm, Confine, Extinguish).

Question 13

What should the nurse do to prevent a patient from aspirating during a seizure?

Accepted Answer

Turning the patient onto their side helps keep the airway clear and allows any secretions to drain out of the mouth, reducing the risk of aspiration.

Question 14

What should the nurse do to promote patient understanding and security in the health care setting?

Accepted Answer

Explaining all procedures to the patient promotes understanding and allows the patient to feel more secure in their healthcare experience. Restraints should only be used as a last resort for safety purposes and should never be used as a means of punishment or control. Allowing the patient more time alone and restricting their activity can lead to isolation and feelings of helplessness, which can negatively impact their mental and emotional health.

Question 15

When caring for a patient who has been restrained,how often will the nurse perform an assessment?

Accepted Answer

When caring for a patient who has been restrained, the nurse should perform assessments every 15 minutes to ensure the patient's safety and comfort. Restraints can cause physical and emotional distress, so frequent assessments are necessary to prevent complications such as injuries, agitation, or anxiety. The nurse should check the patient's vital signs, skin integrity, and hydration status, as well as their level of consciousness, orientation, and mood. The nurse should also offer fluids, nutrition, and toileting assistance as needed, and document all observations and interventions in the patient's medical record.

Question 16

A patient is taking a medication that has the potential to cause orthostatic hypotension.Which of the following nursing interventions is appropriate for this patient?

Accepted Answer

Having the patient sit slowly and dangle their legs will allow their body time to adjust to the change in position and potentially prevent orthostatic hypotension. Referring the patient to physical therapy, keeping the side rails up at all times, and obtaining a walker or cane may be appropriate for other patient situations, but they do not directly address the potential for orthostatic hypotension.

Question 17

A thumbless device used to restrain patients' hands to prevent them from dislodging invasive equipment,removing dressings,or scratching is known as a(n)_____________.

Accepted Answer

A mitten restraint is a thumbless device used to restrain patients' hands to prevent them from dislodging invasive equipment, removing dressings, or scratching.

Question 18

Given the most common causes of hospital fires,which of the following choices are most appropriate in preventing patient injury?

Accepted Answer

D  Ensuring electrical devices are checked can prevent electrical fires, and educating patients on smoking cessation can reduce fire risks associated with smoking.

Question 19

A patient is well known to the hospital staff from previous admissions and is prone to wandering at night.For patient safety,the physician writes a prescription for "belt restraint prn." What should the nurse do on reviewing this prescription?

Accepted Answer

The answer of A patient is well known to the...

Question 20

In a long-term care facility,an elderly patient drops his burning cigarette into a trashcan and starts a fire.A type _____ fire extinguisher is the most appropriate type of fire extinguisher for the nurse to use in this situation.

Accepted Answer

Type A fire extinguishers are used for ordinary combustibles such as wood,cloth,paper,and plastic.A trash can fire would require a type A fire extinguisher.Type B fire extinguishers are used for flammable liquids such as gasoline,grease,paint,and anesthetic gas.Type C fire extinguishers are used for electrical fires.There is no type D fire extinguisher.

Quiz 14: Patient Safety