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Chapter 27: Patient Safety

Test Bank
MULTIPLE CHOICE
1. A home health nurse is performing a home assessment for safety. Which of the following

comments by the patient would indicate a need for further education?


I will schedule an appointment with a chimney inspector next week.
Daylight savings is the time to change batteries on the carbon monoxide detector.
If I feel dizzy when using the heater, I need to have it inspected.
When it is cold outside in the winter, I can warm my car up in the garage.

a.
b.
c.
d.

ANS: D

Allowing a car to run in the garage introduces carbon monoxide into the environment and
decreases the available oxygen for human consumption. Garages should be opened and not
just cracked to allow fresh air into the space and allay this concern. Checking the chimney and
heater, changing the batteries on the detector, and following up on symptoms such as
dizziness, nausea, and fatigue are all statements that would indicate that the individual has
understood the education.
DIF: Remember
REF: 366
OBJ: Describe environmental hazards that pose risks to a persons safety.
TOP: Evaluation
MSC: Safe and Effective Care Environment: Safety and Infection Control
2. The nurse is caring for an elderly patient admitted with nausea, vomiting, and diarrhea. Upon

completing the health history, which priority concern would require collaboration with social
services to address the patients health care needs?
a. The electricity was turned off 2 days ago.
b. The water comes from the county water supply.
c. A son and family recently moved into the home.
d. The home is not furnished with a microwave oven.
ANS: A

Electricity is needed for refrigeration of food, and lack of electricity could have contributed to
the nausea, vomiting, and diarrheapotential food poisoning. This discussion about the
patients electrical needs can be referred to social services. The water supply, the increased
number of individuals in the home, and not having a microwave may or may not be concerns
but do not pertain to the current health care needs of this patient.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 366


Describe environmental hazards that pose risks to a persons safety.
Implementation
Safe and Effective Care Environment: Safety and Infection Control

3. The patient has been diagnosed with a respiratory illness and complains of shortness of breath.

The nurse adjusts the temperature to facilitate the comfort of the patient. What is the usual
comfort range for most patients?
a. 65 F to 75 F
b. 60 F to 75 F
c. 15 C to 17 C

d. 25 C to 28 C
ANS: A

The comfort zone for most individuals is the range between 65 F and 75 F (18.3 C to 23.9
C). The other ranges do not reflect the average persons comfort zone.
DIF: Remember
REF: 366
OBJ: Describe environmental hazards that pose risks to a persons safety.
TOP: Implementation
MSC: Physiological Integrity: Basic Care and Comfort
4. A homeless adult patient presents to the emergency department. The nurse obtains the

following vital signs: temperature 94.8 F, blood pressure 100/56, apical pulse 56, respiratory
rate 12. Which of the vital signs should be addressed immediately?
a. Respiratory rate
b. Temperature
c. Apical pulse
d. Blood pressure
ANS: B

Hypothermia is defined as a core body temperature of 95 F or below. Homeless individuals


are more at risk for hypothermia owing to exposure to the elements.
DIF: Remember
REF: 366
OBJ: Describe environmental hazards that pose risks to a persons safety.
TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation
5. The nurse is caring for a patient with a urinary catheter. After the nurse empties the collection

bag and disposes of the urine, the next step is to


Use alcohol-based gel on hands.
Wash hands with soap and water.
Remove eye protection and dispose of in garbage.
Remove gloves and dispose of in garbage.

a.
b.
c.
d.

ANS: D

After disposing of the urine, the first step in removing personal protective equipment is
removing gloves and disposing of them properly. In this scenario, the next step would be to
remove eye protection followed by hand hygiene. Wash hands if the hands are visibly soiled;
otherwise the use of alcohol-based gel is indicated for routine decontamination of hands.
DIF:
OBJ:
TOP:
MSC:

Remember
REF: 367| 369
Discuss methods to reduce physical hazards and transmission of pathogens.
Implementation
Safe and Effective Care Environment: Safety and Infection Control

6. The nurse is preparing a patient for surgery. The nurse explains that the reason for writing in

indelible ink on the surgical site the word correct is to


Distinguish the correct surgical site.
Label the correct patient.
Comply with the surgeons preference.
Adhere to the correct regulatory standard.

a.
b.
c.
d.

ANS: A

The purpose of writing on the surgical site as part of the Universal Protocol from the Joint
Commission is to distinguish the correct site on the correct patient and match with the correct
surgeon for patient safety and prevention of wrong site surgery. All patients who are having an
invasive procedure should receive labeling in many different ways, including the record and
patient armbands. Writing in indelible ink may comply with the surgeons preference, but
safety is the driving factor. Although labeling of the site helps to meet regulatory standards,
this is not the reason to do this activitythe reason is to keep the patient safe.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 370-371


Describe the four categories of safety risks in a health care agency.
Implementation
Physiological Integrity: Reduction of Risk Potential

7. The nurse identifies that a patient has received Mylanta (simethicone) instead of the

prescribed Pepto-Bismol (bismuth subsalicylate) for the problem of indigestion. The nurses
next intervention is to
a. Do nothing, no harm has occurred.
b. Assess and monitor the patient.
c. Notify the physician, treat and document.
d. Complete an incident report.
ANS: B

After providing an incorrect medication, assessing and monitoring the patient to determine the
effects of the medication is the first step. Notifying the physician and providing treatment
would be the best next step. After the patient has stabilized, completing an incident report
would be the last step in the process.
DIF: Apply
REF: 369-371
OBJ: Define the knowledge, skills, and attitudes necessary to promote safety in a health care setting.
TOP: Assessment MSC: Physiological Integrity: Pharmacological and Parenteral Therapies
8. The nurse preceptor recognizes the new nurses ability to determine patient safety risks when

which behavior is observed?


Checking patient identification once every shift
Multitasking by gathering two patients medications
Disposing of used needles in a red needle container
Raising all four side rails per family request

a.
b.
c.
d.

ANS: C

Needles, syringes, and other single-use injection devices should be used once and disposed of
in safety red needle containers that will be disposed of properly. Patient identification should
be checked multiple times a day, including before each medication, treatment, procedure,
blood administration, and transfer, and at the beginning of each shift. Gathering more than one
patients medication increases the likelihood of error. Raising all four side rails is considered a
restraint and requires special orders, assessment, and monitoring of the patient.
DIF: Analyze
REF: 369| 371| 374| 386
OBJ: Define the knowledge, skills, and attitudes necessary to promote safety in a health care setting.
TOP: Diagnosis
MSC: Physiological Integrity: Reduction of Risk Potential

9. The nurse is completing discharge education for the patient regarding home medications.

Which patient behavior is an indication that the patient understands the directions regarding
the antibiotic medication?
a. The patient nods throughout the educational session.
b. The patient reads the medication prescription out loud.
c. The patient states, I will finish the antibiotic in ten days.
d. The patient asks where to get the prescription filled.
ANS: C

The patient stating the time frame for when the medication will be complete is the best
answer. Nodding, reading the prescription out loud, or knowing where to get the prescription
filled does not indicate understanding regarding directions for taking the antibiotic.
DIF: Evaluate
REF: 369
OBJ: Define the knowledge, skills, and attitudes necessary to promote safety in a health care setting.
TOP: Evaluation
MSC: Physiological Integrity: Pharmacological and Parenteral Therapies
10. The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to
a. Learning to walk.
b. Trying to pull up on furniture.
c. Being dropped by a caregiver.
d. Growing ability to explore and oral activity.
ANS: D

Injury is a leading cause of death in children over age 1, which is closely related to normal
growth and development because of the childs increased oral activity and growing ability to
explore the environment.
DIF: Remember
REF: 368
OBJ: Discuss specific risks to safety related to developmental age.
TOP: Evaluation
MSC: Safe and Effective Care Environment: Safety and Infection Control
11. A nurse is teaching a community group of school-aged parents about safety. The most

important item to prioritize and explain is how to check the proper fit of
a bicycle helmet.
swimming goggles.
soccer shin guards.
baseball sliding shorts.

a.
b.
c.
d.

ANS: A

Bicycle-related injuries are a major cause of death and disability among children. Proper fit of
the helmet helps to decrease head injuries resulting from bicycle accidents. Goggles, shin
guards, and sliding shorts are important sports safety equipment and should fit properly, but
they do not protect from this leading cause of death.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 368


Discuss specific risks to safety related to developmental age.
Implementation | Teaching/Learning
Safe and Effective Care Environment: Safety and Infection Control

12. The nurse is presenting an educational session on safety for parents of adolescents. The nurse

should include which of the following teaching points?

a.
b.
c.
d.

Adolescents need unsupervised time with friends two to three times a week.
Parents and friends should teach adolescents how to drive.
Adolescents need information about the effects of beer on the liver.
Adolescents need to be reminded to use seatbelts on long trips.

ANS: C

Providing information about drugs and alcohol is important because adolescents may choose
to participate in risk-taking behaviors. Adolescents need to socialize but need supervision.
Parents can encourage and support learning processes associated with driving, but organized
classes can help to decrease motor vehicle accidents. Seatbelts should be used all the time.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 368


Discuss specific risks to safety related to developmental age.
Implementation
Safe and Effective Care Environment: Safety and Infection Control

13. The nurse discussed threats to adult safety with a college group. Which of the following

statements would indicate understanding of the topic?


Our campus is safe; we leave our dorms unlocked all the time.
As long as I have only two drinks, I can still be the designated driver.
I am young, so I can work nights and go to school with 2 hours sleep.
I guess smoking even at parties is not good for my body.

a.
b.
c.
d.

ANS: D

Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and
cardiovascular disease. It is prudent to secure belongings. When an individual has been
determined to be the designated driver, that individual does not consume alcohol, beer, or
wine. Sleep is important no matter the age of the individual and is important for rest and
integration of learning. The average young adult needs 6 1/2 to 8 hours of sleep each night.
DIF: Understand REF: 368-369
OBJ: Discuss specific risks to safety related to developmental age.
TOP: Evaluation
MSC: Safe and Effective Care Environment: Safety and Infection Control
14. The nurse is teaching a group of older adults at an assisted-living facility about age-related

physiological changes. Which question would be the most important to ask this group?
Are you able to hear the tornado sirens in your area?
Are you able to read your favorite book?
Are you able to remember the name of the person you just met?
Are you able to open a jar of pickles?

a.
b.
c.
d.

ANS: A

The ability to hear safety alerts and seek shelter is imperative to life safety. Although agerelated changes may cause a decrease in sight that affects reading, and although difficulties in
remembering short-term information and opening jars as arthritis sets in are important to
patients and to those caring for them, being able to hear safety alerts is the priority.
DIF: Apply
REF: 369| 390
OBJ: Discuss specific risks to safety related to developmental age.
TOP: Assessment MSC: Safe and Effective Care Environment: Safety and Infection Control

15. The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the

nurse to consider the need for restraint?


The patient refuses to call for help to go to the bathroom.
The patient continues to remove the nasogastric tube.
The patient gets confused regarding the time at night.
The patient does not sleep and continues to ask for items.

a.
b.
c.
d.

ANS: B

Restraints are utilized only when alternatives have been exhausted, the patient continues a
behavior that can be harmful to himself or others, and the restraint is clinically justified. In
this circumstance, continuing to remove a needed nasogastric tube would meet these criteria.
Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at
night regarding the time or not sleeping and bothering the staff to ask for items is not a reason
for restraint.
DIF: Understand REF: 384-386
OBJ: Describe assessment activities designed to identify patients physical, psychosocial, and
cognitive status as it pertains to their safety.
TOP: Assessment
MSC: Physiological Integrity: Reduction of Risk Potential
16. The nurse is discussing with a patients physician the need for restraint. The nurse indicates

that alternatives have been utilized. What behaviors would indicate that the alternatives are
working?
a. The patient continues to get up from the chair at the nurses station.
b. The patient apologizes for being such a bother.
c. The patient folds three washcloths over and over.
d. The sitter leaves the patient alone to go to lunch.
ANS: C

Offering diversionary activities such as something to hold is a way to keep the hands busy and
provides an alternative to restraints. Assigning a room near the nurses station or a chair at the
desk can be an alternative for continuous monitoring. Getting up constantly can be cause for
concern. Apologizing is not an alternative to restraints. Having a sitter sit with the patient to
keep him occupied can be an alternative to restraints, but the sitter needs to be continuous.
DIF: Understand REF: 384-386
OBJ: Describe assessment activities designed to identify patients physical, psychosocial, and
cognitive status as it pertains to their safety.
TOP: Evaluation
MSC: Physiological Integrity: Reduction of Risk Potential
17. The nurse is caring for a patient who suddenly becomes confused and tries to remove an

intravenous infusion. The nurse begins to develop a plan to care for the patient. Which nursing
intervention should take priority?
a. Gather restraint supplies.
b. Try alternatives to restraint.
c. Assess the patient.
d. Call the physician for a restraint order.
ANS: C

When a patient becomes suddenly confused, the priority is to assess the patient, including
checking laboratory test and oxygen status and treating and eliminating the cause of the
change in mental status. If interventions and alternatives are exhausted, the nurse working
with the physician may determine the need for restraints.
DIF: Apply
REF: 384-386| 388-394
OBJ: Describe assessment activities designed to identify patients physical, psychosocial, and
cognitive status as it pertains to their safety.
TOP: Planning
MSC: Physiological Integrity: Reduction of Risk Potential
18. The nurse knows that four categories of risk have been identified in the health care

environment. Which of the following provides the best examples of those risks?
a. Tile floors, cold food, scratchy linen, and noisy alarms
b. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach
c. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not

functioning properly
d. Dirty floors, hallways blocked, medication room locked, and alarms set
ANS: C

The four categories are falls, patient-inherent accidents, procedure-related accidents, and
equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient
inherent, failure to use the lift is procedure related, and an alarm not functioning properly is
equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to
falls. Cold food, ice machine empty, and hallways blocked are not patient-inherent issues in
the hospital setting but are more of patient satisfaction or infection control issues or fire safety
issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not
procedure-related accidents. These are patient satisfaction issues and control of supply issues,
and are examples of actually following a procedure correctly. Noisy alarms, call light within
reach, and alarms set are not equipment-related accidents but are patient satisfaction issues
and examples of following a procedure correctly.
DIF: Understand REF: 371
OBJ: Describe the four categories of risk in the health care agency.
TOP: Evaluation
MSC: Physiological Integrity: Reduction of Risk Potential
19. Equipment-related accidents are risks in the health care agency. The nurse assesses for this

risk when using


Sequential compression devices.
A measuring device that measures urine.
Computer-based documentation.
A manual medication-dispensing device.

a.
b.
c.
d.

ANS: A

Sequential compression devices are used on a patients extremities to assist in prevention of


deep vein thrombosis and have the potential to malfunction and harm the patient. Measuring
devices used by the nurse to measure urine, computer documentation, and manual dispensing
devices can break or malfunction but are not used directly on a patient.
DIF: Remember
REF: 371
OBJ: Describe the four categories of risk in the health care agency.
TOP: Assessment MSC: Physiological Integrity: Reduction of Risk Potential

20. A patient has been admitted and placed on fall precautions. The nurse explains to the patient

that interventions for the precautions include


Encouraging visitors in the early evening.
Placing all four side rails in the up position.
Checking on the patient once a shift.
Placing a high risk for falls armband on the patient.

a.
b.
c.
d.

ANS: D

Placing a high risk for falls armband on the patient encourages communication among the
whole interdisciplinary team. Anyone who interacts with the patient should see this armband,
understand its meaning, and assist the patient as necessary. The timing of visitors would not
affect falls. All four side rails are considered a restraint and can contribute to falling.
Individuals on high risk for fall alerts should be checked frequently, at least every hour.
DIF:
OBJ:
TOP:
MSC:

Understand REF: 371| 373| 381| 383


Describe the four categories of risk in the health care agency.
Implementation
Physiological Integrity: Reduction of Risk Potential

21. A patient with an intravenous infusion requests a new gown after bathing. Which of the

following actions is most appropriate?


a. Disconnect the intravenous tubing, thread the end through the sleeve of the old

gown and through the sleeve of the new gown, and reconnect.
b. Thread the intravenous bag and tubing through the sleeve of the old gown and

through the sleeve of the new gown without disconnecting.


c. Inform the patient that a new gown is not an option while receiving an intravenous

infusion in the hospital.


d. Call the charge nurse for assistance because linen use is monitored and this is not a

common procedure.
ANS: B

Procedure-related accidents such as contamination of sterile items can occur in the health care
setting. Keeping the intravenous tubing intact without breaks in the system is imperative to
decrease the risk of infection while changing a patients gown and satisfying the patients
request.
DIF:
OBJ:
TOP:
MSC:

Apply
REF: 371
Describe the four categories of risk in the health care agency.
Implementation
Safe and Effective Care Environment: Safety and Infection Control

22. The nurse is precepting a student nurse and is careful to check with the student all components

of the medication process. The nurse explains to the student that most errors occur in
Ordering and transcribing.
Dispensing and administering.
Dispensing and transcribing.
Ordering and administering.

a.
b.
c.
d.

ANS: D

Most medication errors occur in the ordering and administering stages of the medication
process.

DIF:
OBJ:
TOP:
MSC:

Remember
REF: 370-371| 374
Describe the four categories of risk in the health care agency.
Implementation
Physiological Integrity: Reduction of Risk Potential

23. During the admission assessment, the nurse assesses the patient for fall risk. Which of the

following has the greatest potential to increase the patients risk for falls?
The patient is 59 years of age.
The patient walks 2 miles a day.
The patient takes Benadryl (diphenhydramine) for allergies.
The patient recently became widowed.

a.
b.
c.
d.

ANS: C

Benadryl (diphenhydramine) has the potential to cause drowsiness and dizziness as a side
effect, thereby increasing the risk for falls. Over 60 is the age typically found on fall
assessments that increase the risk for falls. Walking has many benefits, including increasing
strength, which would be beneficial in decreasing risk. Becoming widowed would increase
stress and may affect concentration but is not the greatest risk.
DIF: Understand REF: 371| 373-374
OBJ: Describe the four categories of risk in the health care agency.
TOP: Diagnosis
MSC: Physiological Integrity: Reduction of Risk Potential
24. The older patient presents to the emergency department after stepping in front of a car at a

crosswalk. After the patient has been triaged, the nurse interviews the patient. Which of the
following comments would require follow-up by the nurse?
a. I try to exercise, so I walk that block almost every day.
b. I waited and stepped out when the traffic sign said go.
c. The car was going too fast, the speed limit is 20.
d. I was so surprised; I didnt see or hear the car coming.
ANS: D

The patient did not see or hear the car coming. As patients age, sensory impairment can
increase the risk for injury. This statement by the patient would require follow-up by the
nurse. The patient needs hearing and eye examinations. Exercise is important at every stage of
development. The patient seemed to comprehend how to cross an intersection correctly and
was able to determine the speed of the car.
DIF: Understand REF: 369
OBJ: Describe assessment activities designed to identify patients physical, psychosocial, and
cognitive status as it pertains to their safety.
TOP: Diagnosis
MSC: Physiological Integrity: Reduction of Risk Potential
25. The patient presents to the clinic with a family member. The family member states that the

patient has been wandering around the house and mumbling. What is the first assessment the
nurse should do?
a. Ask the patient why she has been wandering around the house.
b. Introduce self and ask the patient her name.
c. Take the patients blood pressure, pulse, temperature, and respiratory rate.
d. Immediately do a complete head-to-toe neurologic assessment.

ANS: B

Introduce self and engage the patient by asking her name to assess orientation; ask the patient
why she is visiting the clinic today. Continue the assessment with vital signs and a complete
workup, including a neurologic assessment.
DIF: Apply
REF: 369
OBJ: Describe assessment activities designed to identify patients physical, psychosocial, and
cognitive status as it pertains to their safety.
TOP: Assessment
MSC: Health Promotion and Maintenance
26. The emergency department has been notified of a potential bioterrorist attack. The nurse

assigned to the department realizes that the most important task for safety in this situation is to
Carry out the role and responsibilities of the nurse quickly and efficiently.
Cluster all patients with the same symptoms to a specific part of the department.
Determine the biologic agent and manage all patients using Standard Precautions.
Prepare for post-traumatic stress associated with this bioterrorist attack.

a.
b.
c.
d.

ANS: C

It is essential to determine the agent and manage all patients who are symptomatic with the
suspected or confirmed bioterrorism-related illness using Standard Precautions. For certain
diseases, additional precautions may be necessary. Clustering patients may be helpful with
staffing and, depending on the illness, may decrease the spread. All nurses every day should
carry out their roles quickly and efficiently. Psychosocial concerns are important but are not
the first priority at this moment.
DIF: Apply
REF: 387-388
OBJ: Describe assessment activities designed to identify patients physical, psychosocial, and
cognitive status as it pertains to their safety.
TOP: Implementation
MSC: Safe and Effective Care Environment: Safety and Infection Control
27. The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion

tubing. These data would help to support a nursing diagnosis of


Risk for poisoning.
Knowledge deficit.
Impaired home maintenance.
Risk for injury.

a.
b.
c.
d.

ANS: D

The patients behaviors support the nursing diagnosis of risk for injury. The patient is
confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could
result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the
scenario indicates that this patient lacks knowledge or is at risk for poisoning. Nothing in the
scenario refers to the patients home maintenance.
DIF: Understand REF: 375
OBJ: Identify relevant nursing diagnoses associated with risk to safety.
TOP: Diagnosis
MSC: Safe and Effective Care Environment: Safety and Infection Control
28. A confused patient is restless and continues to try to remove his oxygen and urinary catheter.

What is the priority nursing diagnosis and intervention to implement for this patient?
a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.
b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary

catheter.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Caregiver role strain: Identify resources to assist with care.
ANS: A

The priority nursing diagnosis is risk for injury. This patient could cause harm to himself by
interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out.
Before restraining a patient, it is important to implement and exhaust alternatives to restraint.
Alternatives can include distraction and providing companionship or supervision. Patients
may be moved to a location closer to the nurses station; trained sitters or family members
may be involved. Nurses need to ensure that patients are provided adequate food, liquid,
toileting, and relief from pain. If these and other alternatives fail, this individual may need
restraints; in this case, an order would need to be obtained for the restraint. This patient may
have deficient knowledge; educating the patient about treatments could be considered as an
alternative to restraints; however, the nursing diagnosis of highest priority is risk for injury.
This scenario does not indicate that the patient has a disturbed body image or that the patients
caregiver is strained.
DIF: Apply
REF: 375| 384-385
OBJ: Identify relevant nursing diagnoses associated with risk to safety.
TOP: Diagnosis
MSC: Safe and Effective Care Environment: Safety and Infection Control
29. The patient applies sequential compression devices after going to the bathroom. The nurse

checks the patients application of the devices and finds that they have been put on upside
down. Which of the following nursing diagnoses will the nurse add to the patients plan of
care?
a. Risk for poisoning
b. Deficient knowledge
c. Risk for imbalanced body temperature
d. Risk for suffocation
ANS: B

The patient needs to understand the purpose of the compression devices and that proper
application is needed for them to be effective. The patient has a knowledge need and requires
instruction regarding the device and its purpose and procedure. The nurse will intervene by
teaching the patient about the sequential compression device and instructing the patient to call
for assistance when getting up to go to the bathroom in the future, so that the nurse may assist
with removal and proper reapplication. No data support a risk for poisoning, imbalanced body
temperature, or suffocation.
DIF: Apply
REF: 375
OBJ: Identify relevant nursing diagnoses associated with risk to safety.
TOP: Diagnosis
MSC: Safe and Effective Care Environment: Safety and Infection Control
30. The nurse enters the patients room and notices a small fire in the headlight above the patients

bed. Immediately, the nurse assigns a nursing diagnosis of risk for injury with a goal for the
patient to be safe. Which of the following actions should the nurse take first?
a. Activate the alarm.
b. Extinguish the fire.
c. Remove the patient.
d. Confine the fire.

ANS: C

Nurses use the mnemonic RACE to set priorities in case of fire. All of these interventions are
necessary, but this patient is in immediate danger with the fire being over his head and should
be rescued and removed from the situation.
DIF:
OBJ:
TOP:
MSC:

Apply
REF: 386-387
Develop a nursing care plan for patients whose safety is threatened.
Implementation
Safe and Effective Care Environment: Safety and Infection Control

31. The nurse is providing information regarding safety and accidental poisoning to a

grandmother who will be taking custody of a 1-year-old grandchild. Which of the following
comments would indicate that the grandmother needs further instruction?
a. The number for poison control is 800-222-1222.
b. Never induce vomiting if my grandchild drinks bleach.
c. I should call 911 if my grandchild loses consciousness.
d. If my grandchild eats a plant, I should provide syrup of ipecac.
ANS: D

Syrup of ipecac to induce vomiting after ingestion of a poison has not been proven effective in
preventing poisoning. This medication should not be administered to the child. The poison
control number is 800-222-1222. After a caustic substance such as bleach has been drunk, do
not induce vomiting. This can cause further burning and injury as the medication is
eliminated. Loss of consciousness associated with poisoning requires calling 911.
DIF: Understand REF: 367
OBJ: Describe nursing interventions specific to patient age for reducing risks of falls, fires,
poisonings, and electrical hazards.
TOP: Evaluation
MSC: Safe and Effective Care Environment: Safety and Infection Control
32. An elderly patient presents to the hospital with a history of falls, confusion, and stroke. The

nurse determines that the patient is at high risk for falls. Which of the following interventions
is most appropriate for the nurse to take?
a. Place the patient in restraints.
b. Lock beds and wheelchairs when transferring.
c. Place a bath mat outside the tub.
d. Silence fall alert alarm upon request of family.
ANS: B

Locking the bed and wheelchairs when transferring will help to prevent these pieces of
equipment from moving during transfer and will assist in the prevention of falls. Patients are
not automatically placed in restraints. The restraint process consists of many steps, including
thorough assessment and exhausting of alternatives. All mats and rugs should be secured to
help prevent falls. Silencing alarms upon the request of family is not appropriate and could
contribute to an unsafe environment.
DIF: Understand REF: 371| 373-374
OBJ: Describe nursing interventions specific to patient age for reducing risks of falls, fires,
poisonings, and electrical hazards.
TOP: Implementation
MSC: Safe and Effective Care Environment: Safety and Infection Control

33. The nurse has been called to a hospital room where a patient is using a hair dryer from home.

The patient has received an electrical shock from the dryer. The patient is unconscious and is
not breathing. What is the best next step?
a. Ask the family to leave the room.
b. Check for a pulse.
c. Begin compressions.
d. Defibrillate the patient.
ANS: B

In this scenario, the patient is in a hospital setting, and it has been determined that the patient
is not conscious and is not breathing. The next step is to check the pulse. An electrical shock
can interfere with the hearts normal electrical impulses and can cause arrhythmias. Checking
the pulse helps to determine the need for cardiopulmonary resuscitation (CPR) and
defibrillation.
DIF: Apply
REF: 379| 387
OBJ: Describe nursing interventions specific to patient age for reducing risks of falls, fires,
poisonings, and electrical hazards.
TOP: Implementation
MSC: Safe and Effective Care Environment: Safety and Infection Control
34. A nurse is in the hallway assisting a patient to ambulate and hears an alarm sound. What is the

best next step for the nurse to take?


a. Seek out the source of the alarm.
b. Wait to see if the alarm discontinues.
c. Ask another nurse to check on the alarm.
d. Continue ambulating the patient.
ANS: C

The nurse who heard the alarm has a duty to address it even though she is busy with another
patient. Ask someone to check on the alarm. The nurse cannot leave the patient in the hallway
to look for the source of the alarm and cause a potentially unsafe situation for this patient, but
a patient on the unit may have an urgent need. Someone needs to seek out the source of the
alarm and address it. Never ignore an alarm. Alarms are in place to maximize the safety of the
patient. Waiting to see if an alarm stops may cause a delay in a possible emergency situation.
DIF: Apply
REF: 385-386
OBJ: Describe nursing interventions specific to patient age for reducing risks of falls, fires,
poisonings, and electrical hazards.
TOP: Assessment
MSC: Safe and Effective Care Environment: Safety and Infection Control
35. The nurse has placed a patient on high-risk alert for falls. Which of the following observations

by the nurse would indicate that the patient has an understanding of this alert?
The patient removes the high alert armband to bathe.
The patient wears the red nonslip footwear.
The call light is kept on the bedside table.
The patient insists on taking a water pill on home schedule in the evening.

a.
b.
c.
d.

ANS: B

Red nonslip footwear helps to grip the floor and decreases the chance of falling. The
communication armband should stay in place and should not be removed, so that all members
of the interdisciplinary team have the information about the high risk for falls. Call lights
should be kept within reach of the patient. Taking diuretics early in the day assists with
decreasing the number of bathroom trips at nightthe time when falls are most frequent.
DIF: Evaluate
REF: 371| 373-374
OBJ: Define the knowledge, skills, and attitudes necessary to promote safety in a health care setting.
TOP: Evaluation
MSC: Safe and Effective Care Environment: Safety and Infection Control
36. The nurse is instructing the student nurse regarding discharge teaching and medications.

Which response by the student would indicate that learning has occurred?
a. I need to be precise when teaching a patient about Zyprexa (olanzapine) and

Zyrtec (cetirizine).
b. The medications can be picked up at the pharmacy on the way out of the hospital.
c. I need to be sure to give the patient leftover medications from the medication

drawer.
d. I need to remember to teach the patient to take all medications at the same time of

the day.
ANS: A

Zyprexa and Zyrtec are sound-alike, look-alike medications. Zyprexa is an antipsychotic and
Zyrtec an antihistamine; these agents treat two different conditions. Bringing the differences
and similarities in spelling and sound to the attention of the patient is important for patient
safety. Medications are not distributed by the hospital, and medications do not need to be
administered at the same time each day.
DIF: Evaluate
REF: 370-371
OBJ: Define the knowledge, skills, and attitudes necessary to promote safety in a health care setting.
TOP: Evaluation
MSC: Physiological Integrity: Pharmacological and Parenteral Therapies
MULTIPLE RESPONSE
1. A nurse is caring for an adult patient who has had a minor motor vehicle accident. The health

history reveals that the patient is currently in the process of obtaining a divorce. Which of the
following actions should the nurse take? (Select all that apply.)
a. Agree upon and make time for the patient to talk.
b. Use active listening skills and therapeutic touch as appropriate.
c. Teach stress reduction strategies.
d. Inform patient that stressed individuals are more likely to have accidents.
e. Agree to witness telephone conversations with separated husband.
f. Refer the patient to the nurses church marriage counselor.
ANS: A, B, C, D

Agreeing and making time for conversation, using active listening skills and therapeutic
touch, teaching stress reduction strategies, and informing the patient of the risk to health
associated with stress are interventions that are within the nurses scope of practice. Agreeing
to witness a telephone conversation could draw the nurse into divorce proceedings when the
focus should be on the patient and his health. Referring the patient to the nurses church
counselor without a specific request from the patient may not take into consideration cultural
care and could be considered unprofessional. If the patient requested a marriage counselor, a
better solution would be to provide a referral to social services that may include a list of
possible counselors from which the patient could choose.
DIF: Apply
REF: 369| 378
OBJ: Discuss specific risks to safety related to developmental age.
TOP: Implementation
MSC: Psychosocial Integrity
2. The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews

fall prevention in the home. Which of the following should the patient avoid? (Select all that
apply.)
a. Watering outdoor plants with a nozzle and hose
b. Purchasing light bulbs with strength greater than 60 watts
c. Missing yearly eye examinations
d. Using bathtubs without safety strips
e. Unsecured rugs throughout the home
f. Walking to the mailbox in the summer
ANS: A, C, D, E

Unsecured rugs, using a hose to water plants, missing yearly eye examinations, and using tubs
without safety strips are all items the patient should avoid to help in the prevention of falls in
the home. Exercise is beneficial and increases strength, which helps with the prevention of
falls. It is important that the home is well lit, so encourage the purchase of bulbs with strength
of 60 watts or higher for the home.
DIF:
OBJ:
TOP:
MSC:

Apply
REF: 369| 372-374
Discuss specific risks to safety related to developmental age.
Implementation
Safe and Effective Care Environment: Safety and Infection Control

3. Which of the following concepts are important to utilize when evaluating orders for restraints?

(Select all that apply.)


Behaviors that necessitate the use of restraint are part of the nursing plan of care.
A physicians order is required for restraint and includes a face-to-face evaluation.
The physicians preference for the format of the order can override agency policy.
Orders are time limited. Restraints are not ordered prn (as needed).
It should be specified that restraints are to be removed periodically.
Restraint orders are time dated and signed by the physician.

a.
b.
c.
d.
e.
f.

ANS: B, D, E, F

Physicians are responsible for writing restraint orders and conducting face-to-face evaluations,
as well as for putting time limits, specifying when to remove, and time dating and signing
orders. Behaviors that necessitate the use of restraint not only are part of the nursing
documentation but are to be included as part of the order for restraint. The physicians
formatting is not a consideration for evaluating restraint orders. Formatting of restraint orders
typically follows state rules and regulations, as well as regulatory agency standards.
DIF: Apply
REF: 384-386| 388-394
OBJ: Identify the factors to be assessed when a patient is in restraints.
TOP: Evaluation
MSC: Safe and Effective Care Environment: Management of Care
4. The nurse suspects the possibility of a bioterrorist attack. Which of the following factors is

most likely related to this possibility? (Select all that apply.)


a. A rapid increase in patients presenting with fever or respiratory or gastrointestinal
symptoms
b. Lower rates of symptoms among patients who spend time primarily indoors
c. Large number of rapidly fatal cases of patients with presenting symptoms
d. Shortage of personal protective equipment available from central supply
e. An increase in the number of staff calling in sick for their assigned shift
f. Patients with symptoms all coming from one location in the area
ANS: A, B, C, F

A rapid increase in patients presenting with a specific symptom, lower rates of symptoms
among individuals indoors, and large numbers of fatalities with these symptoms all coming
from one location are triggers that lead the nurse to suspect a bioterrorist attack. A shortage of
personal protective equipment and an increase in the number of staff calling in sick can occur
and does occur at times in the hospital setting and may have nothing to do with bioterrorism.
DIF: Apply
REF: 387
OBJ: Describe assessment activities designed to identify patients physical, psychosocial, and
cognitive status as it pertains to their safety.
TOP: Assessment
MSC: Safe and Effective Care Environment: Safety and Infection Control
5. The nurse is completing an admission history on a new home health patient. The patient has

been experiencing seizures as the result of a recent brain injury. The nurse diagnoses risk for
injury with a goal of keeping the patient safe in the event of a seizure. Which interventions
should the nurse utilize for this patient? (Select all that apply.)
a. Teach the family how to insert an oral airway during the seizure.
b. Assess the home for items that could harm the patient during a seizure.
c. Provide information on how to obtain a Medical Alert bracelet.
d. Teach the patient to communicate to the caregiver plans for bathing.
e. Discuss with family steps to take if the seizure does not discontinue.
f. Demonstrate how to restrain the patient in the event of a seizure.
ANS: B, C, D, E

Assessment of the home for safety, providing information on Medical Alert bracelets, teaching
the patient to communicate before bathing, and discussing steps to take with status epilepticus
are important interventions for the patient who is having seizures. Inserting an airway may
harm the patient by forcing the object into the mouth or by biting down on a hard object.
Never restrain a patient who is having a seizure, but protect the patient from hitting his body
on objects around him to prevent traumatic injury.

DIF:
OBJ:
TOP:
MSC:

Apply
REF: 387
Develop a nursing care plan for patients whose safety is threatened.
Implementation
Safe and Effective Care Environment: Safety and Infection Control

6. The home health nurse is caring for a patient in the home who is using an electrical infusion

device. While visiting the patient, the nurse smells smoke and notices an electrical fire started
by this device. The nurse uses the fire extinguisher and fights the fire when (Select all that
apply.)
a. All occupants have left the home.
b. Fire department has been called.
c. Fire is confined to one room.
d. An exit route is available.
e. The correct extinguisher is available.
f. The nurse thinks she can use the fire extinguisher.
ANS: A, B, D, E

In a home setting, if the nurse is present during a fire, she first should remove all occupants
and then should call the fire department by dialing 911. If the fire is smallnot confined to
just one room (this could be too large for the fire extinguisher), if the correct extinguisher is
available, and if the nurse knows (not thinks) that she can use it, the nurse may attempt to
extinguish the fire. Utilize PASS (Pull the pin, Aim low, Squeeze the handles, Sweep area
from side to side) to activate the extinguisher.
DIF:
OBJ:
TOP:
MSC:

Apply
REF: 386-387
Develop nursing care plans for patients whose safety is threatened.
Implementation
Safe and Effective Care Environment: Safety and Infection Control

7. The nurse is caring for a group of medical-surgical patients. The unit has been notified of a

fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the
patients safe. Which of the following should the nurse implement? (Select all that apply.)
a. Close all doors.
b. Note evacuation routes.
c. Note oxygen shut-offs.
d. Await direction from the fire department.
e. Evacuate everyone from the building.
f. Review Stop, drop, and roll with the nursing staff.
ANS: A, B, C, D

Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen
shut-offs is important in case the direction to evacuate comes from established channels.
Evacuation from the building is determined by the established chain of command or the fire
department. Evacuation is done only when necessary. Review of stop, drop, and roll,
although important, is not a priority at this time.
DIF: Apply
REF: 386-387
OBJ: Describe nursing interventions specific to patient age for reducing risks of falls, fires,
poisonings, and electrical hazards.
TOP: Implementation
MSC: Safe and Effective Care Environment: Safety and Infection Control

8. The nurse is caring for a patient in restraints. Which of the following pieces of information

about restraints requires nursing documentation in the medical record? (Select all that apply.)
The patient states that her gown is soiled and needs changing.
Attempts to distract the patient with television are unsuccessful.
The patient has been placed in bilateral wrist restraints at 0815.
One family member has gone to lunch.
Bilateral radial pulses present, 2+, hands warm to touch
Released from restraints, active range-of-motion exercises complete

a.
b.
c.
d.
e.
f.

ANS: B, C, E, F

Attempts at alternatives are documented in the medical record, as are type of restraint and
time restrained. Assessments related to oxygenation, orientation, skin integrity, circulation,
and position are documented, along with release from restraints and patient response.
Comments about hygiene or the activities of one family member are not necessarily required
in nursing documentation of restraints.
DIF: Apply
REF: 384-386
OBJ: Describe nursing interventions specific to patient age for reducing risks of falls, fires,
poisonings, and electrical hazards.
TOP: Implementation
MSC: Safe and Effective Care Environment: Safety and Infection Control