Question 1

A patient at risk for falling is being ambulated.Which action by the nurse is most important to prevent the patient from falling?

Accepted Answer

Placing nonskid shoes on the patient provides traction and stability, reducing the risk of slipping and falling during ambulation.

Question 2

A child had surgery on the face and needs to keep the hands away from the surgical site.Which restraint should the nurse use to accomplish this outcome?

Accepted Answer

Elbow restraints are used to prevent a child from bending their arms and touching their face, making them suitable for protecting facial surgical sites.

Question 3

A patient has been wandering and is at risk for falling.Which approach by the nurse regarding the use of chemical and physical restraints in the long-term care setting should be considered initially?

Accepted Answer

The nurse should initially implement alternative measures to address the patient's wandering and fall risk before considering the use of chemical or physical restraints, as restraints should be a last resort.

Question 4

The nurse finds the patient pulling on the nasogastric tube (NGT) and surgical drain and fears that the patient will pull them out.Which nursing intervention should the nurse implement to maintain the patient's self-esteem and avoid applying restraints?

Accepted Answer

Covering or camouflaging tubes and drains can help prevent the patient from being reminded of them, reducing the likelihood of pulling them out, while maintaining the patient's dignity and self-esteem without using restraints.

Question 5

The nurse plans a restraint-free environment but cannot find activities to engage an agitated middle-aged patient.Which should the nurse implement to maintain the patient's safety?

Accepted Answer

The nurse should request help from interdisciplinary team members to find appropriate activities or interventions to engage the patient and maintain safety without using restraints.

Question 6

The nurse participates in the investigation of an incident in the agency.As a result of the root cause analysis, what would the nurse expect as the ultimate outcome?

Accepted Answer

Root cause analysis aims to identify underlying issues and develop a plan to prevent future incidents, rather than assigning blame.

Question 7

The patient is having a generalized tonic-clonic seizure.To maintain the airway, which intervention should the nurse implement after the patient's motor activity ceases?

Accepted Answer

Turning the patient to the side helps maintain an open airway and allows any secretions to drain out of the mouth, reducing the risk of aspiration.

Question 8

Although the interdisciplinary team is responsible for the safety of the patient, who has the ultimate responsibility for making the patient's bedside area safe?

Accepted Answer

The nurse has the ultimate responsibility for ensuring the patient's bedside area is safe, as they are directly involved in patient care and monitoring.

Question 9

The nurse is caring for an older patient who has a non-weight-bearing cast on the left lower extremity.The patient ambulates without using a walker despite repeated instruction from the nurse to call for assistance.Which response by the nurse is most likely to keep the patient from falling?

Accepted Answer

Planning fall prevention with the patient, family, and health care provider involves collaboration and education, which can empower the patient to understand the risks and adhere to safety measures, thereby reducing the likelihood of falling.

Question 10

The nurse is orienting a group of new nurses and explaining the concept of sentinel events and their causes.What should the nurse explain as a common root cause of all sentinel event?

Accepted Answer

Communication failures are often identified as a common root cause of sentinel events, as they can lead to misunderstandings and errors in patient care.

Question 11

The nurse is instructing a patient who has a difficult-to-control seizure disorder on home care issues.Which issue affecting safety is most important for the nurse to address with patient teaching before discharge?

Accepted Answer

The answer of The nurse is instructing a patient who...

Question 12

The daughter of a patient tells the nurse that using the bathroom is embarrassing for the patient and she refuses to use a nurse call system when she needs to get up.Which is the best response by the nurse?

Accepted Answer

Discussing nurse call system alternatives with the patient and daughter addresses the patient's concerns and provides a solution that respects her dignity and autonomy.

Question 13

The nurse listens to a family's request to bring a few familiar items into the room of a patient who is confused.What response by the nurse is best?

Accepted Answer

Personal items can provide comfort and a sense of familiarity to a confused person, potentially reducing anxiety and agitation.

Question 14

The nurse plans care for a patient who requires physical restraint.Which is a suitable goal for this patient?

Accepted Answer

The primary goal when using physical restraints is to ensure the patient's safety and prevent injury.

Question 15

The nurse plans a safety program for the patients on a medical-surgical unit.Which patient has the greatest likelihood of falling?

Accepted Answer

The 68-year-old anemic patient who is dehydrated and has heart failure is at the greatest risk of falling due to potential dizziness, weakness, and instability associated with anemia and dehydration.

Question 16

The nurse discovers smoke in the second-floor utility room.What intervention should he or she implement first?

Accepted Answer

The first priority in a fire situation is to rescue anyone in immediate danger to ensure their safety.

Question 17

The patient wearing bilateral wrist restraints complains hand numbness, and the nurse assesses pale, cool fingers.Which is the nurse's priority intervention?

Accepted Answer

The priority intervention is to remove the wrist restraints to restore circulation and prevent further injury, as the numbness and pale, cool fingers indicate compromised blood flow.

Question 18

The nurse applies a physical restraint to the patient.Which entry should the nurse make after applying the restraint?

Accepted Answer

The nurse should document the type of restraint applied and the condition of the patient's skin to ensure proper monitoring and safety.

Question 19

The nurse plans a fall prevention program for a confused patient.Which task from the program is suitable for the nurse to delegate to nursing assistive personnel (NAP)?

Accepted Answer

Keeping the patient's bed in the low position at all times is a task that can be delegated to nursing assistive personnel as it involves basic safety measures rather than assessment or education.

Question 20

The patient sustains a minor leg abrasion and stops breathing for a few seconds during a tonic-clonic seizure.Which is the best nursing documentation after the patient's seizure?

Accepted Answer

The answer of The patient sustains a minor leg abrasion...

Quiz 4: Patient Safety and Quality Improvement