Chapter 25: Safety Answers for Review Questions 1. Which action should be taken when attempting to decrease falls in the hospital setting? a. Lower the height of the bed and the bottom two side rails before leaving the room. b. Ask patients on first encounter to use the bathroom and every 4 hours thereafter. c. Instruct patients to use the call light only if they think they need help getting out of bed. d. Encourage patients to not take any prescribed medicine that could cause drowsiness or light headedness. Answer: a Keeping the bed in the lowest position and lowering the bottom side rails decreases the chance of a fall. Hourly rounding for toileting is recommended to improve patient safety. Patients should always use a call light to get up even if they do not think they need it. Patients should take prescribed medications but may need assistance with ambulation. LO: 25.7 Bloom’s: Applying NCLEX Client Needs: Safe and Effective Care Environment: Accident/Error/Injury Prevention 2. The nurse demonstrates proper use of a fire extinguisher by taking which action first? a. Sweep from side to side b. Pull the pin c. Squeeze the handles together d. Aim and approach the fire Answer: b Copyright © 2023 by Elsevier, Inc. All rights reserved. The pin must be pulled to break the seal and activate the fire extinguisher. When using a fire extinguisher, remembering the PASS acronym (i.e., pull, aim, squeeze, and sweep) ensures proper technique. LO: 25.7 Bloom’s: Applying NCLEX Client Needs: Safe and Effective Care Environment: Safety and Infection Control 3. A nurse is assessing a patient in restraints. The nurse observes correct use of restraints by checking which of the following? a. Restraint is tied in a secure knot. b. Restraint is secured to the bedrail. c. Restraint allows for 3 to 4 fingers width between restraint and patient’s wrist. d. Restraint is secured to the bedframe. Answer: d Restraints should be secured to a part of the bed that moves with the patient. The bedframe allows for a secure area to attach. The restraint should always be tied in a quick release knot that can be easily untied in an emergency. The recommendation is for two finger widths of space between the restraint and the patient’s extremity. LO: 25.7 Bloom’s: Applying NCLEX Client Needs: Safe and Effective Care Environment: Use of Restraints/Safety Devices Copyright © 2023 by Elsevier, Inc. All rights reserved. 4. What actions should be taken when caring for an 80-year-old postoperative patient with a history of Parkinson’s disease? a. Ensure that all four side rails are elevated. b. Instruct family that they cannot leave the room. c. Place wrists in soft restraints to protect invasive lines. d. Include hourly rounding in the plan of care. Answer: d Hourly rounding prevents patient falls and addresses patient care needs. Four side rails are considered a restraint. Restraints are used only if other measures to keep the patient safe have been tried and failed. It is the nurse’s responsibility to care for the patient; families are not required to be with patients at all times. LO: 25.6 Bloom’s: Applying NCLEX Client Needs: Safe and Effective Care Environment: Safety and Infection Control 5. The nurse is caring for a patient requiring parenteral anticoagulant therapy. Which of the following actions should the nurse take to maximize patient safety? (Select all that apply.) a. Double-check order and dosage with another RN. b. Administer medication using a smart IV infusion pump. c. Administer heparin only through a central venous catheter. d. Monitor glucose every 6 hours. e. Assess and document IV site every 8 hours. Answer: a, b Copyright © 2023 by Elsevier, Inc. All rights reserved. Double-checking the order and dose with another RN can prevent errors. Using an IV smart pump to administer anticoagulants increases correct dose administration. Heparin can be administered through a peripheral line. Glucose is not a focus of anticoagulant therapy. IV access requires more frequent monitoring than every 8 hours. LO: 25.3 Bloom’s: Applying NCLEX Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies 6. The nurse implements the necessary safety precautions in an environment for a patient by doing which of the following? (Select all that apply.) a. Place bed in lowest position with brakes locked. b. Put both upper side rails up while patients are in bed. c. Move personal belongings within reach. d. Place bedside table between patient and the bathroom to use as a resting area. e. Ensure that all patients have bedside commode access. Answer: a, b, c The safest bed position is lowest to the ground and secure (brakes intact) with the upper two side rails elevated. Raising all four side rails is restrictive and should not be used. Having personal belongings within reach minimizes patients moving about to get items. The bedside table has wheels and is not stable to use for resting. It creates an obstacle for the patient to navigate on the way to the bathroom and would be better placed on the opposite side of the bed from the bathroom. Some patients are able to walk to the bathroom; therefore, they do not require a bedside commode. LO: 25.3 Copyright © 2023 by Elsevier, Inc. All rights reserved. Bloom’s: Analyzing NCLEX Client Needs: Safe and Effective Care Environment: Safety and Infection Control 7. The nurse would understand the need for further safety education when a parent makes which of the following statements? a. “I secure my 8-month-old in a rear-facing car seat in the back seat.” b. “My 10-year-old is angry that I still make him use a booster seat and he is not permitted to ride in the front seat.” c. “My 2-month-old sleeps the longest when I put him in his crib on his stomach.” d. “All of our household cleaners are stored in the upper cabinets in my home.” Answer: c Infants should be placed on their backs to sleep to prevent sudden infant death syndrome. The other statements all agree with safety recommendations and show an understanding of correct behavior. LO: 25.1 Bloom’s: Applying NCLEX Client Needs: Safe and Effective Care Environment: Accident/Error/Injury Prevention 8. A patient is being discharged and several previous medications are being discontinued. The patient asks the nurse what she should do with unused medications. The nurse demonstrates knowledge of proper disposal of medications by which of the following? (Select all that apply.) a. Encouraging the patient to use a drug take-back location if available Copyright © 2023 by Elsevier, Inc. All rights reserved. b. Telling the patient to check the label and, if approved, flush the medication down the toilet c. Encouraging the patient to donate the unused medication to a local hospital for use d. Teaching the patient to add coffee grounds to the medication, put in a sealed bag, and dispose in the trash. e. Checking to see whether the patient’s family members could benefit from the medication. Answer: a, b, d Drug take-back locations are the recommended disposal method for unused and expired medications. If a medication can be flushed down the toilet, this is the next recommended way to discard medication. Since some may not be able to be flush, they should be mixed with an undesirable substance, placed in a sealed bag, and then disposed of. Medications are not meant to be shared; thus, they should not be sent to a health care facility or given to a family member. LO: 25.3 Bloom’s: Applying NCLEX Client Needs: Safe and Effective Care Environment: Accident/Error/Injury Prevention 9. Which of the following interventions by the nurse addresses a National Patient Safety Goal as indicated by The Joint Commission? a. Take a picture of the patient upon admission to verify patient identity. b. Answer patient call alarms in a timely manner. c. Provide patients a permanent marker to label all of their medications. d. Use hand sanitizer as the best option for hand hygiene. Copyright © 2023 by Elsevier, Inc. All rights reserved. Answer: b One of the patient safety goals focuses on reducing harm associated with clinical alarm systems. A nurse responding to a patient alarm in a timely manner indicates that the alarm can be heard and the patient condition is being assessed. Patients should be identified by scanning barcodes or comparing the patient’s stated name and birthdate to information on the patient’s wristband or health record. Patients are encouraged to leave medications in labeled bottles. Handwashing remains the most effective hand hygiene technique. LO: 25.1 Bloom’s: Applying NCLEX Client Needs: Safe and Effective Care Environment: Accident/Error/Injury Prevention 10. The nurse is providing discharge instructions on ways to prevent falls at home. Which of the following guidelines are helpful in preventing falls? (Select all that apply.) a. Always wear socks when walking to protect your feet when ambulating. b. Remove rugs that can slip; use rubber mats instead. c. Use your walker or cane even if only moving short distances. d. Use lightweight, easily moveable chairs to assist with mobility. e. Put frequently used items in easy-to-reach places. f. Use handrails when available. Answer: b, c, e, f Hard-soled shoes with a back or nonskid slippers should be worn instead of socks. Chairs should be sturdy with arms and not move for increased safety. Interventions to decrease falls include Copyright © 2023 by Elsevier, Inc. All rights reserved. replacing rugs with rubber mats that will not skid or slip, using ambulatory devices and handrails, and placing frequently used items within easy reach. LO: 25.7 Bloom’s: Applying NCLEX Client Needs: Safe and Effective Care Environment: Accident/Error/Injury Prevention Copyright © 2023 by Elsevier, Inc. All rights reserved.
