NURS 262: EXAM 1 QUESTIONS AND ANSWERS
WITH COMPLETE SOLUTIONS GRADED A++
asphyxation
suffocation - lack of oxygen due to interrupted breathing
safety monitoring devices
items like bed alarms or chair alarms that sound when the client attempts to get up
- bed and chair alarms should only be used for clients who are confused or will
not reliably call for help
Seizure precautions
- wear medical ID if needed
- inspect antieleptic medications and confirm blood levels if needed
- discuss safety precautions inside and outside the home.
- discuss what precipitates a seizure
- determine who in the community should be aware of these seizures
scald
To burn with hot liquid or steam
Heimlich maneuver
an emergency procedure to help someone who is choking because food is lodged in the
trachea - if a patient appears to be choking, ask them to speak to attempt at discovering
if airway is blocked completely or partially
carbon monoxide
,a colorless, odorless, and poisonous gas that should have alarm detectors in every
home and building to prevent a leak from harming anyone
physical restraints
use of an intervention or device that hinders the client from moving or restricts the
individual from contact with his or her body (leather or cloth wrist and ankle restraints,
soft belts or vests, hand mitts, enclosure beds)
seclusion
isolation from others, solitude - in the hospital setting this may be implemented for
safety
chemical restraints
using a medication to control behavior or restrict client's freedom of movement - not a
standard treatment
burn
excessive exposure to thermal, chemical, electric, or radioactive agents
RACE
rescue, alarm, confine, extinguish/evacuate
PASS
Pull, Aim, Squeeze, Sweep
ABC's of nursing
airway, breathing, circulation
electric shock
current travels through the body to the ground, or from static electricity building in the
body.
,A nurse sees smoke emerging from the suction equipment being used. Which is
the greatest priority in the event of a fire?
protect the clients
A nurse who is teaching a group of adults 20-40 years old about safety is going to
ensure that which topic is a priority?
automobile crashes
An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He
ambulates with a walker and takes a diuretic medi-cation to control symptoms of
fluid retention. Which intervention is most important to protect him from injury?
provide a bedside commode
A mother and her 3-year-old live in a home built in 1972. Which nursing diagnosis
is most applicable for this child?
potential for poisoning
A 75-year-old client, hospitalized with a stroke, becomes dis-oriented at times and
tries to get out of bed, but is unable to ambulate without help. What is the most
appropriate safety measure?
use a bed exit safety monitoring device
A client is being admitted to the hospital because of a seizure that occurred at his
home. The client has no previous history of seizures. In planning the client's
nursing care, which of the following measures is most essential at this time of
admission? Select all that apply.
pad the bed with blankets, test oral suction equipment
, Which nursing intervention is the highest in priority for a client at risk for falls in
a hospital setting?
place the bed in the lowest position
A confused client is touching his IV line and the nurse is con-cerned for his
safety. The nurse wants to consider options for keeping the IV line from being
pulled out. Which of the following options would best meet the needs of the client
and nurse? Select all that apply.
explain the purpose of the IV line, cover up the IV site with a long sleeved gown,
apply wrist restraints to both wrists, apply a mitt to both hands without attaching straps
rationale: attempt to exhaust all options first before using restraints
When planning to teach healthcare topics to a group of male adolescents, which
topic should the nurse consider a priority
guns are the most frequently used weapon for adolescent suicide
The nurse, at change-of-shift report, learns that one of the cli-ents in his care has
bilateral soft wrist restraints. The client is confused, is trying to get out of bed,
and had pulled out the IV line, which was subsequently reinserted. Which
action(s) by the nurse is appropriate? Select all that apply.
document the behaviors that require continued use of the restraints, provide range of
motion exercises when the restraints are removed, orient the client, assess
tightness of the restraints
rationale: tying restraints to side rails are a hazard. goal is to protect the patient and not
use restraints unless we have to
factors affecting safety
WITH COMPLETE SOLUTIONS GRADED A++
asphyxation
suffocation - lack of oxygen due to interrupted breathing
safety monitoring devices
items like bed alarms or chair alarms that sound when the client attempts to get up
- bed and chair alarms should only be used for clients who are confused or will
not reliably call for help
Seizure precautions
- wear medical ID if needed
- inspect antieleptic medications and confirm blood levels if needed
- discuss safety precautions inside and outside the home.
- discuss what precipitates a seizure
- determine who in the community should be aware of these seizures
scald
To burn with hot liquid or steam
Heimlich maneuver
an emergency procedure to help someone who is choking because food is lodged in the
trachea - if a patient appears to be choking, ask them to speak to attempt at discovering
if airway is blocked completely or partially
carbon monoxide
,a colorless, odorless, and poisonous gas that should have alarm detectors in every
home and building to prevent a leak from harming anyone
physical restraints
use of an intervention or device that hinders the client from moving or restricts the
individual from contact with his or her body (leather or cloth wrist and ankle restraints,
soft belts or vests, hand mitts, enclosure beds)
seclusion
isolation from others, solitude - in the hospital setting this may be implemented for
safety
chemical restraints
using a medication to control behavior or restrict client's freedom of movement - not a
standard treatment
burn
excessive exposure to thermal, chemical, electric, or radioactive agents
RACE
rescue, alarm, confine, extinguish/evacuate
PASS
Pull, Aim, Squeeze, Sweep
ABC's of nursing
airway, breathing, circulation
electric shock
current travels through the body to the ground, or from static electricity building in the
body.
,A nurse sees smoke emerging from the suction equipment being used. Which is
the greatest priority in the event of a fire?
protect the clients
A nurse who is teaching a group of adults 20-40 years old about safety is going to
ensure that which topic is a priority?
automobile crashes
An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He
ambulates with a walker and takes a diuretic medi-cation to control symptoms of
fluid retention. Which intervention is most important to protect him from injury?
provide a bedside commode
A mother and her 3-year-old live in a home built in 1972. Which nursing diagnosis
is most applicable for this child?
potential for poisoning
A 75-year-old client, hospitalized with a stroke, becomes dis-oriented at times and
tries to get out of bed, but is unable to ambulate without help. What is the most
appropriate safety measure?
use a bed exit safety monitoring device
A client is being admitted to the hospital because of a seizure that occurred at his
home. The client has no previous history of seizures. In planning the client's
nursing care, which of the following measures is most essential at this time of
admission? Select all that apply.
pad the bed with blankets, test oral suction equipment
, Which nursing intervention is the highest in priority for a client at risk for falls in
a hospital setting?
place the bed in the lowest position
A confused client is touching his IV line and the nurse is con-cerned for his
safety. The nurse wants to consider options for keeping the IV line from being
pulled out. Which of the following options would best meet the needs of the client
and nurse? Select all that apply.
explain the purpose of the IV line, cover up the IV site with a long sleeved gown,
apply wrist restraints to both wrists, apply a mitt to both hands without attaching straps
rationale: attempt to exhaust all options first before using restraints
When planning to teach healthcare topics to a group of male adolescents, which
topic should the nurse consider a priority
guns are the most frequently used weapon for adolescent suicide
The nurse, at change-of-shift report, learns that one of the cli-ents in his care has
bilateral soft wrist restraints. The client is confused, is trying to get out of bed,
and had pulled out the IV line, which was subsequently reinserted. Which
action(s) by the nurse is appropriate? Select all that apply.
document the behaviors that require continued use of the restraints, provide range of
motion exercises when the restraints are removed, orient the client, assess
tightness of the restraints
rationale: tying restraints to side rails are a hazard. goal is to protect the patient and not
use restraints unless we have to
factors affecting safety
