NUR102: Ch. 27 Safety & Ch. 28 Infection Control

A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?

• 55 years old

• 20/20 vision

• Urinary continence

• Orthostatic hypotension

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the temporary need for a 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.

The nurse is admitting an older adult to the surgical unit. What intervention is necessary when determining the safe use of side rails for this patient?

• Explain to the patient the need to call for assistance when side rails are up.

• Discuss whether the patient is accepting of having the side rails up.

• Assess the patient’s ability to effectively follow instructions.

• Always keeping the bed in its lowest position to the floor.

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take to minimize the patient’s risk for injury?

• Administer an anxiolytic

• Gather restraint supplies.

• Try alternatives to restraint.

• Call the health care provider for a restraint order.

A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?

• Identifies patient with one identifier before transporting to x-ray department.

• Initiates an intravenous (IV) catheter using clean technique on the first try.

• Uses medication bar coding when administering medications.

• Obtains vital signs to place on a surgical patient’s chart.

A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?

• Determining the need for restraints

• Assessing the patient’s orientation

• Obtaining an order for a restraint

• Applying the restraint

A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?

• Remove the restraint.

• Place a blanket over the feet.

• Immediately do a complete head-to-toe neurological assessment.

• Take the patient’s blood pressure, pulse, temperature, and respiratory rate.

The nurse enters the patient’s room and notices a small fire in the headlight above the patient’s bed. In which order will the nurse perform the steps, beginning with the first one?

1. Pull the alarm.

2. Remove the patient.

3. Use the fire extinguisher.

4. Close doors and windows.

• 2, 1, 4, 3

• 1, 2, 4, 3

• 1, 2, 3, 4

• 2, 1, 3, 4

Which patient will the nurse see first?

• A 56-year-old patient with oxygen with a lighter on the bedside table

• A 56-year-old patient with oxygen using an electric razor for grooming

• A 1-month-old infant looking at a shiny, round battery just out of arm’s reach

• A 1-month-old infant with a pacifier that has no string around the baby’s neck

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.)

• Smoking in bed helps me relax and fall asleep.

• We never leave candles burning when we are gone.

• We use the same space heater my grandparents used.

• We use the RACE method when using the fire extinguisher.

• There is a fire extinguisher in the kitchen and garage workshop.