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Chapter 038

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 38: Client Safety MULTIPLE CHOICE 1. The nurse has investigated safety hazards and recognizes that which one of the following statements is accurate regarding safety needs? 1. Bacterial contamination of foods is uncontrollable. 2. Fire is the greatest cause of unintentional death. 3. Carbon dioxide levels should be monitored in home settings. 4. Temperature extremes seldom affect the safety of clients in acute care facilities
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 3: Client !afety #$T%P$E C'%CE 1.The nurse has investigated safety hazards and recognizes that which one of the following statements is accurate regarding safety needs?1.Bacterial contamination of foods is uncontrollable.2.Fire is the greatest cause of unintentional death.3.Carbon dioide levels should be monitored in home settings.!.Tem erature etremes seldom affect the safety of clients in acute care facilities.#$%&3#nnual ins ections of heating systems' chimneys' and a liances should be done in   rivate homes. Carbon monoide detectors are available but should not be used as a re lacement for ro er use and maintenance of fuel(burning a liances. Bacterial contamination of foods is controllable. The F)# is a federal agency res onsible for the enforcement of federal regulations regarding the manufacture' rocessing' and distribution of foods' drugs' and cosmetics to rotect consumers against the sale of im ure or dangerous substances. *otor vehicle accidents are the leading cause of unintentional death' not fire. Tem erature etremes can affect the safety of clients in acute care facilities' es ecially the elderly.+T%&1),F&#-F&/120B&Com rehensionT0+&$ursing +rocess& #ssessment*%C&$C4 test lan designation& %afe' ffective Care nvironment5%afety 6 ,nfection Control2.#n ambulatory client is admitted to the etended care facility with a diagnosis of #lzheimer7s disease. ,n using a falls assessment tool' the nurse 8nows that the greatest indicator of ris8 is&1.Confusion2.,m aired 9udgment3.%ensory deficits!.:istory of falls#$%&!#ccording to the falls assessment tool' the greatest indicator of ris8 is a history of falls. #ccording to the falls assessment tool' the second leading ris8 factor for falls is confusion. #ccording to the falls assessment tool' im aired 9udgment is the fourth leadingris8 factor for falls. #ccording to the falls assessment tool' sensory deficit is the fifth leading ris8 factor for falls.+T%&1),F&#-F&/1;0B&Com rehension *osby items and derived items < 2==>' 2== by *osby' ,nc.' an affiliate of lsevier ,nc.  Test Ban8 T0+&$ursing +rocess& #ssessment*%C&$C4 test lan designation& %afe' ffective Care nvironment5%afety 6 ,nfection Control3.#n inservice rogram is being offered in the hos ital on bioterrorism and the res onse of the health care agency. )uring the rogram' the mitigation hase is described. The nurse is informed that this hase includes&1.)etermination of hazard vulnerability and the im act of the emergency situation2.%te s ta8en to manage the effects of the event and an inventory of available resources3.%te s ta8en by staff to triage victims!.-estoration of essential services#$%&1The mitigation hase consists of the assessment rocess to determine hazard vulnerabilityfor the hos ital7s service area. This includes an identification of the 8inds of emergency situations that are most li8ely to occur and their robable im act. )uring the   re aredness hase' ste s are ta8en to manage the effects of the event' and an inventory of available resources is ta8en. )uring the res onse hase' ste s are ta8en by staff to triage victims. )uring the recovery hase' ste s are ta8en to restore essential services.+T%&1),F&#-F&/210B&Com rehensionT0+&$ursing +rocess& #ssessment*%C&$C4 test lan designation& %afe' ffective Care nvironment5%afety 6 ,nfection Control!.#n inservice rogram is being offered in the hos ital on bioterrorism and the res onse of the health care agency. #n im ortant as ect of the rogram is the recognition of the signs and sym toms of bacterial and viral infections. # ractice drill is held and the nurse recognizes that the clients admitted with ossible anthra will demonstrate&1.#bdominal cram ing' diarrhea' droo ing eyelids' 9aw clench' and difficulty swallowing2.Fluli8e sym toms' gastrointestinal distress' and a ular lesions3.Fever' cough' chest ain' and hemo tysis!.@esicular s8in lesions on the face and etremities#$%&2Clinical features of anthra include fluli8e sym toms' gastrointestinal distress' and   a ular lesions. #bdominal cram ing' diarrhea' droo ing eyelids' 9aw clench' and difficulty swallowing are clinical features of botulism. Fever' cough' chest ain' and hemo tysis are characteristic of lague. @esicular s8in lesions on the face and etremitiesare seen with small o.+T%&1),F&#-F&/210B&Com rehensionT0+&$ursing +rocess& #ssessment *osby items and derived items < 2==>' 2== by *osby' ,nc.' an affiliate of lsevier ,nc. 3/(2  Test Ban8 *%C&$C4 test lan designation& %afe' ffective Care nvironment5%afety 6 ,nfection Control.# 1(year(old child is scheduled to receive an ,@ line. The most a ro riate ty e of restraint to use for this client to revent removal of the ,@ line would be aAn&1.rist restraint2.ac8et restraint3.lbow restraint!.*ummy restraint#$%&!# mummy restraint is used short(term for a small child or infant for eamination or treatment involving the head and nec8. This would be the most a ro riate ty e of restraint to use for a 1(year(old child who is going to receive an ,@ line. The wrist restraint maintains immobility of an etremity to revent the client from removing a thera eutic device' such as an ,@ tube. ,t would not be the best choice for starting an ,@ on a 1(year(old child. The 9ac8et restraint is often used to revent a client from getting u and falling. ,t is not the best choice for starting an ,@ line. #n elbow restraint is commonly used with infants and children to revent elbow fleion' such as after an ,@ line is in lace.+T%&1),F&#-F&/320B&Com rehensionT0+&$ursing +rocess& +lanning*%C&$C4 test lan designation& %afe' ffective Care nvironment5%afety 6 ,nfection ControlD.# ;>(year(old resident in a long(term care facility is 8nown to Ewander at night and has fallen in the ast. hich of the following is the most a ro riate nursing intervention?1.#n abdominal restraint should be laced on the client during slee ing hours.2.The client should be chec8ed freGuently during the night.3.# radio should be left laying at the bedside to assist in reality orientation.!.The client should be laced in a room that is away from the activity of the nurses7 station.#$%&2#lternatives to restraints should be attem ted first. A# hysician7s order is reGuired for restraints to be a lied. The most a ro riate intervention is to chec8 on the client freGuently. #lternatives to restraints should be attem ted first before an abdominal restraint while slee ing.# radio may hel orientate a client to reality. :owever' the most a ro riate intervention for the client who wanders is to chec8 on the client freGuently. Clients who wander should be assigned to rooms near the nurses7 station and chec8ed on freGuently.+T%&1),F&C-F&/320B&#nalysisT0+&$ursing +rocess& +lanning*%C&$C4 test lan designation& %afe' ffective Care nvironment5%afety 6 *osby items and derived items < 2==>' 2== by *osby' ,nc.' an affiliate of lsevier ,nc. 3/(3  Test Ban8 ,nfection Control;.The wor8men cause an electrical fire when installing a new iece of eGui ment in the intensive care unit. # client is on a ventilator in the net room. The first action the nurse should ta8e is to&1.+ull the fire alarm2.#ttem t to etinguish the fire3.Call the hysician to obtain orders to ta8e the client off the ventilator !.Hse an #mbu(bag and remove the client from the area#$%&!,f there is a fire' and the client is on life su ort' the nurse should maintain the client7s res iratory status manually with an #mbu(bag and move the client away from the fire. The first action of the nurse is not to ull the fire alarm. The wor8men could do that. The wor8man can attem t to etinguish the fire. The nurse should attend to the client who is closest to the fire in the net room. The nurse should not call the doctor to obtain orders to ta8e the client off the ventilator because this will ta8e valuable time. The client needs to be moved away from the fire' and the source of oygen needs to be discontinued' as it is combustible. The client will need to be manually resuscitated with an #mbu(bag.+T%&1),F&C-F&/3>0B&#nalysisT0+&$ursing +rocess& ,m lementation*%C&$C4 test lan designation& %afe' ffective Care nvironment5%afety 6 ,nfection Control/.,n a nursing home an elderly client dro s his burning cigarette in a trash can and starts a fire. The most a ro riate ty e of fire etinguisher for the nurse to use is the&1.Ty e #2.Ty e B3.Ty e C!.Ty e )#$%&1Ty e # fire etinguishers are used for ordinary combustibles such as wood' cloth' a er' and lastic. # trash can fire would reGuire a ty e # fire etinguisher. Ty e B fire etinguishers are used for flammable liGuids such as gasoline' grease' aint' and anesthetic gas. Ty e C fire etinguishers are used for electrical eGui ment. There is no ty e ) fire etinguisher.+T%&1),F&#-F&/!=0B&Com rehensionT0+&$ursing +rocess& ,m lementation*%C&$C4 test lan designation& %afe' ffective Care nvironment5%afety 6 ,nfection Control *osby items and derived items < 2==>' 2== by *osby' ,nc.' an affiliate of lsevier ,nc. 3/(!

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