Chapter 19 - Safety

What is the priority cue that indicates Mrs. Patel is at increased fall risk?

• Postoperative status

• Age over 70

• Use of pain medications

• Overnight hospitalization

Which is the most appropriate initial intervention to prevent further incidents?

• Order physical restraints

• Provide hourly rounding and bed alarm

• Place a Foley catheter

• Discontinue pain medication

Mrs. Patel states, “I didn’t want to bother anyone.” Which nursing action supports patient-centered care?

• Say, “You should have used the call light.”

• Tell her to wait next time

• Educate on safety and reinforce call light use

• Increase the dose of pain meds

Which intervention is most appropriate to prevent future wandering?

• Apply wrist restraints

• Use bed alarms and keep patient near nurse's station

• Administer sedatives

• Assign him to a private room

What root cause of wandering must the nurse assess?

• Medication side effects

• Need to urinate

• Pain

• Delusions

Which is the most therapeutic approach when Mr. Greene becomes agitated during redirection?

• Firmly tell him to sit down

• Gently redirect using distraction and familiar items

• Ignore him until he calms down

• Threaten to call family

What is the highest immediate safety concern?

• Contraband possession

• Fire and smoke hazard

• Medication noncompliance

• Aggressive behavior

What is the nurse's first action?

• Call hospital security

• Activate RACE protocol

• Inform the physician

• Document the incident

After ensuring safety, what legal requirement must be met?

• Notify OSHA

• File an incident report

• Re-evaluate her insurance

• Call the Department of Health

What is the nurse’s priority action?

• Call the family

• Return him to bed

• Assess for injury and neuro status

• Complete a fall report