Question 1

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

Accepted Answer

Turning the patient onto their side (recovery position) is the best option to prevent aspiration during a seizure. This allows any fluids or secretions to drain out of the mouth instead of being inhaled into the lungs. An oral airway may not be effective if the patient is actively seizing and clenching their jaw, and restraining the patient is not recommended as it can cause injury and is a violation of the patient's rights. Sitting the patient upright may also not be effective in preventing 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

Having the patient sit slowly and dangle allows time for the patient's body to adjust to the change in position and can help prevent a sudden drop in blood pressure. Referring the patient to physical therapy, keeping the side rails up, or obtaining a walker or a cane may not necessarily address the issue of orthostatic hypotension.

Question 3

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

Accepted Answer

Covering or camouflaging tubes and drains can help to reduce the patient's awareness of them and minimize their desire to tamper with them. Providing constant activity may not always be feasible and could potentially lead to fatigue or overstimulation. Changing caregivers frequently could disrupt the establishment of trust and rapport with one caregiver. Reducing visiting hours and therapy could negatively impact the patient's social and therapeutic support.

Question 4

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 charger needs to be checked by hospital engineers to ensure it is safe and does not interfere with any medical equipment. It is not true that patients are not allowed to bring in an electric wheelchair or that all electrical equipment is banned from hospitals. However, electrical devices should be checked by hospital staff to ensure they are safe to use.

Question 5

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

The initial nursing intervention when a patient begins to have a seizure is to assist the patient to the floor to prevent injury. Calling for assistance should follow immediately after assisting the patient to the floor. Putting the patient back into bed or inserting a padded tongue blade is not appropriate and can cause harm to the patient.

Question 6

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 7

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 side rails raised can actually increase the risk of falls as patients may become disoriented and attempt to climb over the rails to get out of bed. Leaving one lower side rail down can provide a safe exit path for the patient to use the restroom, while still providing some protection from falling. Additionally, falls are a common occurrence in the inpatient setting and can result in serious physical injury, making it important to take measures to prevent them.

Question 8

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

A type A fire extinguisher is designed to extinguish fires fueled by ordinary combustibles such as paper, wood, and cloth. In this situation, the fire is likely fueled by materials in the trash can, which are typically ordinary combustibles. B, C, and D fire extinguishers are designed for different types of fires (flammable liquids, electrical fires, and metals, respectively) and would not be appropriate for this scenario.

Question 9

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 every 2 hours to allow for range of motion exercises and skin checks. Removing the restraint too frequently can cause agitation and discomfort for the patient.

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

Which of the following fall prevention strategies should the nurse perform on all hospitalized patients?

Accepted Answer

The answer of Which of the following fall prevention strategies...

Question 12

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

Accepted Answer

The nurse should explain all procedures to the patient to promote understanding and security in the healthcare setting. Restraint should only be used as a last resort for safety reasons and restricting activity as much as possible can be detrimental to the patient's physical and mental well-being. Allowing the patient more time alone may contribute to feelings of isolation and insecurity.

Question 13

Effective fall prevention programs include which of the following?

Accepted Answer

Effective fall prevention programs should include all of the options listed:

A) Risk assessment - this allows for identification of factors that may increase fall risk and allows for targeted interventions.

B) Medication reviews - many medications can increase fall risk, so reviewing all medications for potential side effects is important.

C) Use of assistive devices - this can include anything from grab bars to walkers, and can help improve mobility and prevent falls.

D) Exercise and strength training - regular exercise and strength training can improve balance and reduce fall risk, especially in older adults.

Therefore, all of these options should be included in an effective fall prevention program.

Question 14

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

Accepted Answer

According to nursing standards, the nurse should assess the restrained patient every 15 minutes to ensure their safety and well-being. This includes checking their circulation, skin condition, vital signs, and mental status.

Question 15

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 16

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 17

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 18

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

Accepted Answer

Government standards regarding mechanical and physical restraints state that alternative measures should be implemented before restraints are used. This promotes patient safety and avoids unnecessary use of restraints. The nurse's judgment alone is not sufficient for restraint use, as alternative measures must be considered first. Restraints should also not be used unless absolutely necessary to prevent harm to the patient or others.

Question 19

A safe health care environment is one in which:

Accepted Answer

The answer of A safe health care environment is one...

Question 20

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.

Quiz 14: Patient Safety