Question 1

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

Accepted Answer

A plan for prevention of a similar event happening again is the ultimate outcome of this investigation.The investigation will determine all contributing factors in the occurrence of the event,with the goal of identifying methods to prevent those failures from recurring.

Question 2

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

According to the standards governing the use of restraints,the nurse must implement several alternative measures in a serious attempt to avoid applying restraints.The patient must be assessed by the healthcare provider before restraints are implemented unless the patient is a serious and imminent risk to self and others.The patient's family is notified in a timely manner but is not an initial consideration.

Question 3

The nurse is caring for a 79-year-old male 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 an individualized fall prevention program with the help of the patient,family,and healthcare provider is more likely to reduce the patient's risk of falls because he gains some control over the plan of care and still benefits from the input of the provider,family,and nurse and the fall prevention program.A combination of interventions is more useful in preventing falls.Including the patient in planning also gives him ownership of the plan,making it less likely that he will disregard a plan he helped to design.Vest restraints are associated with serious injuries and are not recommended for use.Documenting the patient's risk is important because it communicates the information and records the nurse's acknowledgment of the risk,but it is not as effective as engaging the patient in planning care as a prevention technique because it is indirect.Alternative methods of engaging the patient in a care plan that minimizes risks should be exhausted before resorting to restraints.

Question 4

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

Accepted Answer

Describing the seizure in detail is the best documentation after a seizure because it is the most comprehensive item listed and includes the type of muscle contractions observed during the seizure,the description of injuries,how the injuries occurred,and the description of any breathing abnormalities.

Question 5

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 the number one root cause of all sentinel event reports to The Joint Commission?

Accepted Answer

Communication failures are the number one root cause of all sentinel events reported to The Joint Commission.A sentinel event is an unexpected occurrence involving death,serious physical or psychological injury,or risk thereof.Although the other elements may cause sentinel events,they are not the number one root cause.

Question 6

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 surfaces on the patient's feet helps to prevent falls.The height of the bed should be as low as possible before attempting to have the patient stand.Dangling prevents dizziness,but the length of time differs,and it is not required for all patients.Adequate light is important,but the brightest lights are not needed.

Question 7

The nurse is instructing a male 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 most important issue to address is to have him purchase any motorized lawn equipment with a safety switch that will stop the machine when the handle is released.Thus the patient avoids injury if he has a seizure while operating the equipment.Although the patient should avoid alcohol to decrease the risk of possible alcohol-drug interactions,and he should keep a list of current medications to avoid confusion over his therapeutic regimen,failure to do so poses a risk only to himself.Likewise,although keeping a supply of medication at work is a good idea,it is not a safety risk not to do so.

Question 8

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

Patients who have been rolled onto their side during a major motor seizure are at greater risk for self-injury,such as a dislocated shoulder.Since patients are not breathing during a generalized tonic-clonic seizure,they are not at high risk for aspiration until the event ends.Immediately following such a seizure,patients usually take a deep breath.Therefore,a patient should be rolled over onto his or her side immediately after the motor activity ceases.Chin-lift is an effective method of maintaining a patient's airway; however,it does not protect the patient against aspiration.Oral airways are not inserted during a seizure unless the patient's jaw relaxes enough to properly insert the airway without causing tissue damage.The upright position is contraindicated for airway maintenance.

Question 9

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

The nurse may delegate keeping the bed lowered to the NAP because the NAP is trained to perform the task with proper nursing supervision.Skills used to prevent falls can often be delegated.The nurse does not delegate the remaining options because they involve aspects of the nursing process that require the advanced training of a nurse to perform.

Question 10

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 making the patient's bedside area safe.Other personnel assist with their specific roles,but the nurse oversees the safety.

Question 11

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

A nurse's expertise does not include occupational therapy,so the nurse collaborates with other experts to meet the patient's safety and psychosocial needs.After assessing the patient,the experts make recommendations,and the nurse incorporates the activities into the patient's plan of care.Putting the patient in a private room decreases the risk of injury to other patients; but it isolates the patient,increases the need for distraction,and increases the risks to the staff and patient.Documentation should always be descriptive and never judgmental.In this case the nurse would document: "The patient stated,'Stay away.'" Sedation increases the risk of falls from potential adverse effects,including hypotension,dizziness,and confusion.

Question 12

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

The nurse keeps the patient busy with nursing care and activities that provide an effective distraction to limit awareness of the NGT and surgical drain; in this manner the nurse avoids the need for restraints and maintains the patient's self-esteem.Covering or camouflaging the tubes is unlikely to be an effective method of avoiding restraints because the patient is likely to find the tubes despite the disguise.Engaging the family in the care of the patient is reasonable; however,the nurse does not rely on the family to provide nursing care.Keeping the patient out by the nurses' station allows the nurse to observe the patient closely; however,this is likely to lower the patient's self-esteem because his or her problem is on public display.

Question 13

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

Accepted Answer

When restraints become necessary,the patient must remain free of injury; thus the nurse plans frequent neurovascular checks and removes the restraint on a regular basis to inspect the skin for pressure points and breakdown and perform range-of-motion exercises to maintain joint flexibility.Checking the restraint is a nursing intervention; it is not a goal because it is not patient centered.Using the least restrictive restraint can defeat the purpose of a restraint.When a restraint is required,the nurse uses the proper restraint to keep the patient safe and facilitate the therapeutic regimen.This is not a suitable goal because it focuses on the nurse.If the patient or staff members' safety is at risk,the nurse applies restraints without the patient's permission.

Question 14

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

Accepted Answer

The nurse applies bilateral elbow restraints so the child cannot touch the operative area.They prevent elbow flexion.The child will still be able to hug the parent or hold onto objects.Mitten restraints are inadequate because the hands could still access the face.A mummy restraint is used for short-term examination of a child.Although it does confine,the mummy restraint is more like swaddling.The use of jacket restraints has been discouraged because of safety risks associated with their use.

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 patient with anemia and dehydration with heart failure has the highest risk of falling.The patient will be taking other medications,including antihypertensive agents that increase the risk of falls caused by confusion,dizziness,or orthostatic hypotension.The replacement of a pacemaker battery in a stable patient is a low-risk,routine procedure.The 21-year-old recovering from the arthroscopy is most likely a healthy adult who is stable while ambulating.The 33-year-old postsalpingectomy is most likely to be healthy but may be a little hypotensive if much bleeding occurred before surgery.

Question 16

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

Accepted Answer

The nurse documents the type of restraint applied and the condition of the skin where the restraint was placed in the progress notes to communicate the information to the healthcare team.The nurse does not document subjective statements about the nurse.Neurovascular assessments of a patient's extremity must take place at least every 2 hours because skin breakdown can occur very quickly.The nurse does not accept prn prescriptions for restraints according to nursing standards and federal regulations.

Question 17

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

Accepted Answer

The first step after identifying an actual or potential fire is to rescue victims at risk for injury from the fire,including patients,visitors,or staff,to reduce injuries from the fire.The second step is to activate the alarm.The third step is to contain the fire: find the extinguisher and empty the container onto the fire or source of the smoke.Finally the evacuation begins if the fire is uncontrolled or the smoke is excessive.This follows the acronym RACE.

Question 18

The nurse listens to a family's request to bring a few familiar items into the room of a patient who is confused.How does the nurse justify the decision to allow personal items?

Accepted Answer

Personal items can comfort and calm a confused person because familiar items are part of the patient's customary environment,patterns,and habits; in addition,these items personalize an otherwise strange environment and surround the patient with recognizable things.The personal items are likely to engage the patient but on their own do nothing to restore cognitive function.

Question 19

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

Accepted Answer

Discussing call light alternatives with the patient and daughter is the best method of engaging the patient in planning nursing care.This recognizes the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient's preferences,values,and needs.Including the patient in planning alternatives also gives her ownership of the plan and increases the likelihood of cooperation.Asking a "why" question is not an ideal response because it is confrontational and requires the patient to justify feelings.Remaining with the patient is an impractical solution for home care.

Question 20

The female patient wearing bilateral wrist restraints complains that her hands are numb; and the nurse assesses pale,cool fingers.Which is the nurse's priority intervention?

Accepted Answer

The patient displays clinical indicators of neurovascular impairment,and a delay in resolving the problem can result in tissue damage,so the nurse removes the restraint,thoroughly assesses the extremities,and plans nursing care.Before another type of restraint is applied,the nurse completes the assessment and notifies the provider as necessary.Increasing the padding is a reasonable intervention after the nurse's assessment and provider notification.

Quiz 4: Patient Safety and Quality Improvement