Fundamentals: Patient Safety (Test Bank)
1. A home health nurse is performing a home assessment for safety. Which
of the following comments by the patient would indicate a need for further
education?
a. "I will schedule an appointment with a chimney inspector next week."
b. "Daylight savings is the time to change batteries on the carbon monoxide
detector."
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 can warm my car up in the
garage."-: ANS: D
Allowing a car to run in the garage introduces carbon monoxide into the
environment and decreases the available oxygen for human consumption.
Garages should be opened and not just cracked to allow fresh air into the space
and allay this concern. 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 would indicate that the individual has understood
the education.
2. The nurse is caring for an elderly patient admitted with nausea, vomiting,
and diarrhea. Upon completing the health history, which priority concern
would require collaboration with social services to address the patient's
health care needs?
a. The electricity was turned off 2 days ago.
b. The water comes from the county water supply.
c. A son and family recently moved into the home.
d. The home is not furnished with a microwave oven.: ANS: A
Electricity is needed for refrigeration of food, and lack of electricity could have
contributed to the nausea, vomiting, and diarrhea—potential food poisoning. This
discussion about the patient's electrical needs can be referred to social services.
The water supply, the increased number of individuals in the home, and not
having a microwave may or may not be concerns but do not pertain to the current
health care needs of this patient.
3. The patient has been diagnosed with a respiratory illness and complains
of shortness of breath. The nurse adjusts the temperature to facilitate the
comfort of the patient. What is the usual comfort range for most patients?
a. 65° F to 75° F
b. 60° F to 75° F
, Fundamentals: Patient Safety (Test Bank)
c. 15° C to 17° C
d. 25° C to 28° C: ANS: A
The comfort zone for most individuals is the range between 65° F and 75° F (18.3°
C to 23.9° C). The other ranges do not reflect the average person's comfort zone.
4. A homeless adult patient presents to the emergency department. The
nurse obtains the following vital signs: temperature 94.8° F, blood pressure
100/56, apical pulse 56, respiratory rate 12. Which of the vital signs should
be addressed immediately?
a. Respiratory rate
b. Temperature
c. Apical pulse
d. Blood pressure: ANS: B
Hypothermia is defined as a core body temperature of 95° F or below.
Homeless individuals are more at risk for hypothermia owing to exposure to the
elements 5. The nurse is caring for a patient with a urinary catheter. After
the nurse empties the collection bag and disposes of the urine, the next
step is to
a. Use alcohol-based gel on hands.
b. Wash hands with soap and water.
c. Remove eye protection and dispose of in garbage.
d. Remove gloves and dispose of in garbage.: ANS: D
After disposing of the urine, the first step in removing personal protective
equipment is removing gloves and disposing of them properly. In this scenario, the
next step would be to remove eye protection followed by hand hygiene. Wash
hands if the hands are visibly soiled; otherwise the use of alcohol-based gel is
indicated for routine decontamination of hands.
6. The nurse is preparing a patient for surgery. The nurse explains that the
reason for writing in indelible ink on the surgical site the word "correct" is to
a. Distinguish the correct surgical site.
b. Label the correct patient.
c. Comply with the surgeon's preference.
d. Adhere to the correct regulatory standard.: ANS: A
The purpose of writing on the surgical site as part of the Universal Protocol from
the Joint Commission is to distinguish the correct site on the correct patient and
match with the correct surgeon for patient safety and prevention of wrong site
surgery. All patients who are having an invasive procedure should receive labeling
, Fundamentals: Patient Safety (Test Bank)
in many different ways, including the record and patient armbands. Writing in
indelible ink may comply with the surgeon's preference, but safety is the driving
factor. Although labeling of the site helps to meet regulatory standards, this is not
the reason to do this activity—the reason is to keep the patient safe.
7. The nurse identifies that a patient has received Mylanta (simethicone)
instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the
problem of indigestion. The nurse's next intervention is to
a. Do nothing, no harm has occurred.
b. Assess and monitor the patient.
c. Notify the physician, treat and document.
d. Complete an incident report.: ANS: B
After providing an incorrect medication, assessing and monitoring the patient to
determine the effects of the medication is the first step. Notifying the physician and
providing treatment would be the best next step. After the patient has stabilized,
completing an incident report would be the last step in the process.
8. The nurse preceptor recognizes the new nurse's ability to determine
patient safety risks when which behavior is observed?
a. Checking patient identification once every shift
b. Multitasking by gathering two patients' medications
c. Disposing of used needles in a red needle container
d. Raising all four side rails per family request: ANS: C
Needles, syringes, and other single-use injection devices should be used once
and disposed of in safety red needle containers that will be disposed of properly.
Patient identification should be checked multiple times a day, including before
each medication, treatment, procedure, blood administration, and transfer, and at
the beginning of each shift. Gathering more than one patient's medication
increases the likelihood of error. Raising all four side rails is considered a restraint
and requires special orders, assessment, and monitoring of the patient.
9. The nurse is completing discharge education for the patient regarding
home medications. Which patient behavior is an indication that the
patient understands the directions regarding the antibiotic medication?
a. The patient nods throughout the educational session.
b. The patient reads the medication prescription out loud.
c. The patient states, "I will finish the antibiotic in ten days."
d. The patient asks where to get the prescription filled.: ANS: C
1. A home health nurse is performing a home assessment for safety. Which
of the following comments by the patient would indicate a need for further
education?
a. "I will schedule an appointment with a chimney inspector next week."
b. "Daylight savings is the time to change batteries on the carbon monoxide
detector."
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 can warm my car up in the
garage."-: ANS: D
Allowing a car to run in the garage introduces carbon monoxide into the
environment and decreases the available oxygen for human consumption.
Garages should be opened and not just cracked to allow fresh air into the space
and allay this concern. 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 would indicate that the individual has understood
the education.
2. The nurse is caring for an elderly patient admitted with nausea, vomiting,
and diarrhea. Upon completing the health history, which priority concern
would require collaboration with social services to address the patient's
health care needs?
a. The electricity was turned off 2 days ago.
b. The water comes from the county water supply.
c. A son and family recently moved into the home.
d. The home is not furnished with a microwave oven.: ANS: A
Electricity is needed for refrigeration of food, and lack of electricity could have
contributed to the nausea, vomiting, and diarrhea—potential food poisoning. This
discussion about the patient's electrical needs can be referred to social services.
The water supply, the increased number of individuals in the home, and not
having a microwave may or may not be concerns but do not pertain to the current
health care needs of this patient.
3. The patient has been diagnosed with a respiratory illness and complains
of shortness of breath. The nurse adjusts the temperature to facilitate the
comfort of the patient. What is the usual comfort range for most patients?
a. 65° F to 75° F
b. 60° F to 75° F
, Fundamentals: Patient Safety (Test Bank)
c. 15° C to 17° C
d. 25° C to 28° C: ANS: A
The comfort zone for most individuals is the range between 65° F and 75° F (18.3°
C to 23.9° C). The other ranges do not reflect the average person's comfort zone.
4. A homeless adult patient presents to the emergency department. The
nurse obtains the following vital signs: temperature 94.8° F, blood pressure
100/56, apical pulse 56, respiratory rate 12. Which of the vital signs should
be addressed immediately?
a. Respiratory rate
b. Temperature
c. Apical pulse
d. Blood pressure: ANS: B
Hypothermia is defined as a core body temperature of 95° F or below.
Homeless individuals are more at risk for hypothermia owing to exposure to the
elements 5. The nurse is caring for a patient with a urinary catheter. After
the nurse empties the collection bag and disposes of the urine, the next
step is to
a. Use alcohol-based gel on hands.
b. Wash hands with soap and water.
c. Remove eye protection and dispose of in garbage.
d. Remove gloves and dispose of in garbage.: ANS: D
After disposing of the urine, the first step in removing personal protective
equipment is removing gloves and disposing of them properly. In this scenario, the
next step would be to remove eye protection followed by hand hygiene. Wash
hands if the hands are visibly soiled; otherwise the use of alcohol-based gel is
indicated for routine decontamination of hands.
6. The nurse is preparing a patient for surgery. The nurse explains that the
reason for writing in indelible ink on the surgical site the word "correct" is to
a. Distinguish the correct surgical site.
b. Label the correct patient.
c. Comply with the surgeon's preference.
d. Adhere to the correct regulatory standard.: ANS: A
The purpose of writing on the surgical site as part of the Universal Protocol from
the Joint Commission is to distinguish the correct site on the correct patient and
match with the correct surgeon for patient safety and prevention of wrong site
surgery. All patients who are having an invasive procedure should receive labeling
, Fundamentals: Patient Safety (Test Bank)
in many different ways, including the record and patient armbands. Writing in
indelible ink may comply with the surgeon's preference, but safety is the driving
factor. Although labeling of the site helps to meet regulatory standards, this is not
the reason to do this activity—the reason is to keep the patient safe.
7. The nurse identifies that a patient has received Mylanta (simethicone)
instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the
problem of indigestion. The nurse's next intervention is to
a. Do nothing, no harm has occurred.
b. Assess and monitor the patient.
c. Notify the physician, treat and document.
d. Complete an incident report.: ANS: B
After providing an incorrect medication, assessing and monitoring the patient to
determine the effects of the medication is the first step. Notifying the physician and
providing treatment would be the best next step. After the patient has stabilized,
completing an incident report would be the last step in the process.
8. The nurse preceptor recognizes the new nurse's ability to determine
patient safety risks when which behavior is observed?
a. Checking patient identification once every shift
b. Multitasking by gathering two patients' medications
c. Disposing of used needles in a red needle container
d. Raising all four side rails per family request: ANS: C
Needles, syringes, and other single-use injection devices should be used once
and disposed of in safety red needle containers that will be disposed of properly.
Patient identification should be checked multiple times a day, including before
each medication, treatment, procedure, blood administration, and transfer, and at
the beginning of each shift. Gathering more than one patient's medication
increases the likelihood of error. Raising all four side rails is considered a restraint
and requires special orders, assessment, and monitoring of the patient.
9. The nurse is completing discharge education for the patient regarding
home medications. Which patient behavior is an indication that the
patient understands the directions regarding the antibiotic medication?
a. The patient nods throughout the educational session.
b. The patient reads the medication prescription out loud.
c. The patient states, "I will finish the antibiotic in ten days."
d. The patient asks where to get the prescription filled.: ANS: C
