Chapter 27: Patient Safety and Quality
Potter et al.: Fundamentals of Nursing,
9th Edition
A confused patient is restless and continues to try to remove the oxygen cannula and
urinary catheter. What is the priority nursing diagnosis and intervention to implement for
this patient?
a. Risk for injury: Check on patient every 15 minutes.
b. Risk for suffocation: Place "Oxygen in Use" sign on door.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.
- ANS - ANS: A
The priority nursing diagnosis is Risk for injury. This patient could cause harm to self 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 more frequent observations. 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 patient is at risk for suffocation.
DIF:Apply (application)
A home health nurse is assessing a family's home after the birth of an infant. A toddler
also lives in the home. Which finding will cause the nurse to follow up?
a. Plastic grocery bags are neatly stored under the counter.
b. Electric outlets are covered in all rooms.
c. No bumper pads are in the crib.
d. Crib slats are 5 cm apart. - ANS - ANS: A
Plastic grocery bags increase the risk for suffocation. The nurse will follow up with
instructions to remove or keep locked or out of reach. All the rest are correct and do not
require follow-up. Electrical outlets should be covered to reduce electrical shock.
Bumper pads are not used in the crib to prevent suffocation, strangulation, or
entrapment. Crib slats should be less than 6 cm apart.
DIF:Apply (application)
, 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.)
a. Smoking in bed helps me relax and fall asleep.
b. We never leave candles burning when we are gone.
c. We use the same space heater my grandparents used.
d. We use the RACE method when using the fire extinguisher.
e. There is a fire extinguisher in the kitchen and garage workshop. - ANS - ANS: A, C,
D
Incorrect information will cause the nurse to intervene. Accidental home fires typically
result from smoking in bed. Advise families to only purchase newer model space
heaters that have all of the current safety features. The PASS method is used for fire
extinguishers. All the rest are correct and do not require follow-up. Candles should not
be left burning when no one is home. Keep a fire extinguisher in the kitchen, near the
furnace, and in the garage.
DIF:Apply (application)
A home health nurse is performing a home assessment for safety. Which comment by
the patient will cause the nurse to follow up?
a. "Every December is the time to change batteries on the carbon monoxide detector."
b. "I will schedule an appointment with a chimney inspector next week."
c. "If I feel dizzy when using the heater, I need to have it inspected."
d. "When it is cold outside in the winter, I will use a nonvented furnace." - ANS - ANS:
D
Using a nonvented heater introduces carbon monoxide into the environment and
decreases the available oxygen for human consumption and the nurse should follow up
to correct this behavior. 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 are safe and appropriate and need no follow-up.
DIF:Analyze (analysis)
A homeless adult patient presents to the emergency department. The nurse obtains the
following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and
respiratory rate 12. Which vital sign should the nurse address immediately?
a. Respiratory rate
b. Temperature
c. Apical pulse
d. Blood pressure - ANS - ANS: B
The temperature indicates the patient is experiencing hypothermia. Homeless
individuals are more at risk for hypothermia. While all the vital signs are low, the most
critical vital sign at this time is the temperature.
Potter et al.: Fundamentals of Nursing,
9th Edition
A confused patient is restless and continues to try to remove the oxygen cannula and
urinary catheter. What is the priority nursing diagnosis and intervention to implement for
this patient?
a. Risk for injury: Check on patient every 15 minutes.
b. Risk for suffocation: Place "Oxygen in Use" sign on door.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.
- ANS - ANS: A
The priority nursing diagnosis is Risk for injury. This patient could cause harm to self 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 more frequent observations. 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 patient is at risk for suffocation.
DIF:Apply (application)
A home health nurse is assessing a family's home after the birth of an infant. A toddler
also lives in the home. Which finding will cause the nurse to follow up?
a. Plastic grocery bags are neatly stored under the counter.
b. Electric outlets are covered in all rooms.
c. No bumper pads are in the crib.
d. Crib slats are 5 cm apart. - ANS - ANS: A
Plastic grocery bags increase the risk for suffocation. The nurse will follow up with
instructions to remove or keep locked or out of reach. All the rest are correct and do not
require follow-up. Electrical outlets should be covered to reduce electrical shock.
Bumper pads are not used in the crib to prevent suffocation, strangulation, or
entrapment. Crib slats should be less than 6 cm apart.
DIF:Apply (application)
, 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.)
a. Smoking in bed helps me relax and fall asleep.
b. We never leave candles burning when we are gone.
c. We use the same space heater my grandparents used.
d. We use the RACE method when using the fire extinguisher.
e. There is a fire extinguisher in the kitchen and garage workshop. - ANS - ANS: A, C,
D
Incorrect information will cause the nurse to intervene. Accidental home fires typically
result from smoking in bed. Advise families to only purchase newer model space
heaters that have all of the current safety features. The PASS method is used for fire
extinguishers. All the rest are correct and do not require follow-up. Candles should not
be left burning when no one is home. Keep a fire extinguisher in the kitchen, near the
furnace, and in the garage.
DIF:Apply (application)
A home health nurse is performing a home assessment for safety. Which comment by
the patient will cause the nurse to follow up?
a. "Every December is the time to change batteries on the carbon monoxide detector."
b. "I will schedule an appointment with a chimney inspector next week."
c. "If I feel dizzy when using the heater, I need to have it inspected."
d. "When it is cold outside in the winter, I will use a nonvented furnace." - ANS - ANS:
D
Using a nonvented heater introduces carbon monoxide into the environment and
decreases the available oxygen for human consumption and the nurse should follow up
to correct this behavior. 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 are safe and appropriate and need no follow-up.
DIF:Analyze (analysis)
A homeless adult patient presents to the emergency department. The nurse obtains the
following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and
respiratory rate 12. Which vital sign should the nurse address immediately?
a. Respiratory rate
b. Temperature
c. Apical pulse
d. Blood pressure - ANS - ANS: B
The temperature indicates the patient is experiencing hypothermia. Homeless
individuals are more at risk for hypothermia. While all the vital signs are low, the most
critical vital sign at this time is the temperature.
