Question 1

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

Accepted Answer

When the seizure begins,position the patient safely.If the patient is standing or sitting,guide the patient to the floor and protect the head by cradling in the nurse's lap or placing a pillow under the head.Clear the surrounding area of furniture.If the patient is in bed,raise the side rails and pad,and put the bed in a low position.Stay with the patient,and observe the sequence and timing of seizure activity.Continued observation ensures adequate ventilation during and after a seizure and will assist in documentation,diagnosis,and treatment of a seizure disorder.If possible,turn the patient onto one side,with the head tilted slightly forward.This allows the tongue to fall away from the airway,permitting drainage of saliva and vomitus,and prevents aspiration.Do not force any objects such as fingers,medicine or tongue depressor,or airway into the patient's mouth when the teeth are clenched.This could cause injury to the mouth and stimulate gagging,which could lead to aspiration.

Question 2

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

Dangling allows adjustment to orthostatic hypotension,permitting blood pressure to stabilize before ambulating.Have the patient dangle his or her feet for a few minutes before standing,walk slowly,and ask for help if dizzy or weak.The nurse would confer with physical therapy on the feasibility of gait training and muscle-strengthening exercise.Check agency policies regarding side rail use.Side rails are a restraint device if they immobilize or reduce the ability of a patient to move his or her arms,legs,body,or head freely.Keep one side rail up in a two-rail system,and keep three of four rails up (one lower rail down)in a four-rail system,with the bed in low position and wheels locked,when you are not administering patient care.This allows the patient to maneuver and get out of bed safely.Do not assume that the patient requires a walker or a cane.Evaluate the need for assistive devices such as walker,cane,or bedside commode.Assistive devices may provide greater stability and may help the patient to assume a more active role.

Question 3

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

Accepted Answer

Using the "RACE" acronym,the next action the nurse should take is to confine the fire by closing doors and windows and turning off oxygen and electrical equipment (Rescue,Activate,Contain,and Evacuate).Extinguish the fire by using an extinguisher after ensuring patient and individual safety after closing the doors of patient rooms.After activating the alarm,the nurse should close all the doors,not remove all the other patients from the unit.Moving the trash can would not be an appropriate action,as the nurse could get burned in this attempt.

Question 4

Effective fall prevention programs include which of the following? (Select all that apply. )

Accepted Answer

Evidence shows that hospital-based fall prevention programs that focus on a multifactorial approach reduce fall rates (CDC,2006).Effective fall prevention programs include risk assessment,medication reviews with necessary modifications,use of assistive devices,exercise and strength training,and education for home safety.

Question 5

A safe health care environment is one in which: (Select all that apply. )

Accepted Answer

A safe environment is one in which the patient's basic needs are met,physical hazards are reduced or eliminated,transmission of microorganisms is reduced,and sanitary measures are carried out.

Question 6

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

Accepted Answer

Restraints should be removed at least every 2 hours (Joint Commission on Accreditation of Healthcare Organizations [JCAHO],2004).If the patient is violent or noncompliant,remove one restraint at a time and/or have staff assistance while removing restraints.Removal provides an opportunity to change the patient's position,offer nutrients,perform full ROJM,and toilet and exercise the patient.After application,evaluate the patient's condition for signs of injury every 15 minutes.Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time.If the patient shows no sign of impaired circulation or other complications,the restraint does not need to be removed at this time.If the nurse restrains a patient in an emergency situation because of violent or aggressive behavior,this presents an immediate danger;a face-to-face physician assessment is needed within 1 hour to determine the patient's need for the restraint.

Question 7

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

If the patient receives an electrical shock,immediately assess for the presence of a pulse.Electrical shock can cause cardiac arrest,asystole.Do not leave the patient.Only if the patient is pulseless will the nurse institute cardiopulmonary resuscitation.If the patient has a pulse and remains alert and oriented,obtain vital signs and assess the skin for signs of thermal injury.Electrical current will cause burn at points of entry and exit from the body.

Question 8

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

Accepted Answer

If possible,turn the patient onto the side,with the head flexed slightly forward.This position prevents the tongue from blocking the airway and promotes drainage of secretions,thus reducing the risk for aspiration.Do not force any objects such as fingers,medicine or tongue depressor,or airway into the patient's mouth when the teeth are clenched.This could cause injury to the mouth and could stimulate gagging,leading to possible aspiration.Do not restrain the patient.Loosen clothing to prevent musculoskeletal injury and airway obstruction.When a seizure begins,position the patient safely.If the patient is standing or sitting,guide the patient to the floor and protect the head by cradling in the nurse's lap or placing a pillow under the head.Clear the surrounding area of furniture.If the patient is in bed,raise the side rails and pad,and put the bed in a low position.

Question 9

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 an order for "belt restraint prn." What should the nurse do upon reviewing this order?

Accepted Answer

The use of mechanical or physical restraints should be part of a patient's prescribed medical treatment.A physician's time-limited order is necessary.The patient's or family member's informed consent is necessary in the long-term care setting.

Question 10

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 11

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

Accepted Answer

After application,evaluate the patient's condition every 15 minutes for signs of injury.Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time.Observation and frequent assessments prevent complications such as suffocation,skin breakdown,and impaired circulation.The Joint Commission recommends that the patient's condition be evaluated every 15 minutes.If the nurse restrains the patient in an emergency situation because of violent or aggressive behavior that presents an immediate danger,a face-to-face physician assessment within 1 hour is needed to determine the patient's continued need for restraints.Restraints should be removed at least every 2 hours.If the patient is violent or noncompliant,remove one restraint at a time and/or have staff assistance while removing restraints.Removal provides an opportunity to change the patient's position,offer nutrients,perform full range of joint motion (ROJM),and toilet and exercise the patient.

Question 12

In a long-term care facility,an elderly patient drops his burning cigarette into a trash can 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.

Question 13

The patient is admitted to the hospital with orders 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 third (longer)prong in an electrical plug is the ground.If a patient brings an electrical device to the hospital,an engineer inspects the device for safe wiring and function before use.Many patients with disabilities use battery chargers for mobility equipment function.These devices need to be inspected by hospital engineers.Fires in health care settings typically are electrical or anesthetic-related.

Question 14

Which of the following fall prevention strategies should the nurse perform on all hospitalized patients? (Select all that apply. )

Accepted Answer

A recent study shows that hourly nurse rounds are an effective strategy for reducing falls.Combining hourly rounds with activities such as regular toileting and assessing the patient's comfort needs manages those factors that often prompt patients to get out of bed without assistance.In the hospital setting,a variety of fall risk factor screening tools are available.Because multiple risk factors for falls are known,no single assessment tool is sensitive and specific for analyzing fall risk.

Question 15

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

Accepted Answer

The use of mechanical or physical restraints must be part of the prescribed medical treatment,all less-restrictive interventions must be tried first,other disciplines must be applied,and supporting documentation must be provided.If the alternatives fail,the nurse may consider use of a restraint to prevent injury.Determine the patient's need for restraint if other less-restrictive measures fail to prevent interruption of therapy or injury to self or others.Confer with the physician or primary health care provider,who must write the order for restraints.Restraints may be needed for the confused or combative patient to prevent interruption of therapy or injury to self or others.Confer with the physician or primary health care provider.

Question 16

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

Accepted Answer

Fires in health care settings are usually electrical or anesthetic-related,so ensuring all electrical devices are inspected will greatly reduce the risk of fire.Look for inspection labels verifying recent inspection for all electrical devices.Fire door should never be propped open.While educating patients on smoking cessation is a good idea,it will have little impact on immediate hospital safety.Although smoking is no longer allowed in the hospital setting,smoking-related fires continue to pose a risk due to unauthorized smoking in bed or the bathroom.

Question 17

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

Accepted Answer

Orient patient and family to surroundings,introduce to staff,and explain all treatments and procedures.This promotes patient understanding and cooperation.The use of restraints is one safety strategy that can protect patients from injury,but restraints must be used with extreme caution.Physical restraints should be the last resort and should be used only when reasonable alternatives have failed.Isolation may increase anxiety.Encourage family and friends to stay with the patient.Sitters or companions may be used.In some institutions,volunteers can be effective companions.Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant.Constant activity may irritate the patient,yet the lack of activity may create anxiety and/or boredom.Meaningful diversional activities provide distraction,help to reduce boredom,and provide tactile stimulation.Minimize occurrences of wandering.

Question 18

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 19

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

Accepted Answer

Position intravenous (IV)catheters,urinary catheters,and tubes/drains out of patient view,or use camouflage by wrapping the IV site with bandage or stockinette,placing undergarments on patients with a urinary catheter,or covering abdominal feeding tubes/drains with a loose abdominal binder.This helps maintain medical treatment and reduces patient access to tubes/lines.Provide scheduled ambulation,chair activity,and toileting.Organize treatments so the patient has long uninterrupted periods throughout the day.Provide for sleep and rest periods.Constant activity may irritate the patient.Provide the same caregivers to the extent possible.This increases familiarity with individuals in the patient's environment,decreasing anxiety and restlessness.Encourage family and friends to stay with the patient.Sitters or companions may be used.In some institutions,volunteers can be effective companions.Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant.

Question 20

The patient is an elderly gentleman who is admitted for a medical problem.While doing his admission assessment,the nurse learns that the patient gets up 2 to 3 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 four side rails raised often increases the occurrence of falling,because patients try to climb over the rails to reach a chair or bathroom and often fall farther as a result.Leaving three side rails up (two upper and one lower)on a bed with four side rails is safer for the patient.Leaving the lower side rail down on the side of the bed the patient will exit the bed from to access the bathroom reduces the risk of falls.

Quiz 14: Patient Safety