FUNDAMENTALS: PATIENT SAFETY
CLINICAL SKILLS (TEST BANK)
QUESTIONS AND ANSWERS
The patient is confused, is trying to get out of bed, and is pulling at the intravenous
infusion tubing. These data would help to support a nursing diagnosis of
a. Risk for poisoning.
b. Knowledge deficit.
c. Impaired home maintenance.
d. Risk for injury. - Answer-ANS: D
The patient's behaviors support the nursing diagnosis of risk for injury. The patient is
confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury
could result if the patient falls out of bed or begins to bleed from a pulled line.
Nothing in the scenario indicates that this patient lacks knowledge or is at risk for
poisoning. Nothing in the scenario refers to the patient's home maintenance.
A confused patient is restless and continues to try to remove his oxygen and urinary
catheter. What is the priority nursing diagnosis and intervention to implement for this
patient?
a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.
b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary
catheter.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Caregiver role strain: Identify resources to assist with care. - Answer-ANS: A
The priority nursing diagnosis is risk for injury. This patient could cause harm to
himself 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 distraction and providing
companionship or supervision. Patients may be moved to a location closer to the
nurses' station; trained sitters or family members may be involved. Nurses need to
ensure that patients are provided adequate food, liquid, toileting, and relief from pain.
If these and other alternatives fail, this individual may need restraints; in this case, an
order would need to be obtained for the restraint. 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's caregiver is strained.
The patient applies sequential compression devices after going to the bathroom. The
nurse checks the patient's application of the devices and finds that they have been
put on upside down. Which of the following nursing diagnoses will the nurse add to
the patient's plan of care?
a. Risk for poisoning
b. Deficient knowledge
c. Risk for imbalanced body temperature
d. Risk for suffocation - Answer-ANS: B
, The patient needs to understand the purpose of the compression devices and that
proper application is needed for them to be effective. The patient has a knowledge
need and requires instruction regarding the device and its purpose and procedure.
The nurse will intervene by teaching the patient about the sequential compression
device and instructing the patient to call for assistance when getting up to go to the
bathroom in the future, so that the nurse may assist with removal and proper
reapplication. No data support a risk for poisoning, imbalanced body temperature, or
suffocation.
The nurse enters the patient's room and notices a small fire in the headlight above
the patient's bed. Immediately, the nurse assigns a nursing diagnosis of risk for injury
with a goal for the patient to be safe. Which of the following actions should the nurse
take first?
a. Activate the alarm.
b. Extinguish the fire.
c. Remove the patient.
d. Confine the fire. - Answer-ANS: C
Nurses use the mnemonic RACE to set priorities in case of fire. All of these
interventions are necessary, but this patient is in immediate danger with the fire
being over his head and should be rescued and removed from the situation.
The nurse is providing information regarding safety and accidental poisoning to a
grandmother who will be taking custody of a 1-year-old grandchild. Which of the
following comments would indicate that the grandmother needs further instruction?
a. "The number for poison control is 800-222-1222."
b. "Never induce vomiting if my grandchild drinks bleach."
c. "I should call 911 if my grandchild loses consciousness."
d. "If my grandchild eats a plant, I should provide syrup of ipecac." - Answer-ANS: D
Syrup of ipecac to induce vomiting after ingestion of a poison has not been proven
effective in preventing poisoning. This medication should not be administered to the
child. The poison control number is 800-222-1222. After a caustic substance such as
bleach has been drunk, do not induce vomiting. This can cause further burning and
injury as the medication is eliminated. Loss of consciousness associated with
poisoning requires calling 911.
The nurse is teaching a group of older adults at an assisted-living facility about age-
related physiological changes. Which question would be the most important to ask
this group?
a. "Are you able to hear the tornado sirens in your area?"
b. "Are you able to read your favorite book?"
c. "Are you able to remember the name of the person you just met?"
d. "Are you able to open a jar of pickles?" - Answer-ANS: A
The ability to hear safety alerts and seek shelter is imperative to life safety. Although
age-related changes may cause a decrease in sight that affects reading, and
although difficulties in remembering short-term information and opening jars as
arthritis sets in are important to patients and to those caring for them, being able to
hear safety alerts is the priority.
CLINICAL SKILLS (TEST BANK)
QUESTIONS AND ANSWERS
The patient is confused, is trying to get out of bed, and is pulling at the intravenous
infusion tubing. These data would help to support a nursing diagnosis of
a. Risk for poisoning.
b. Knowledge deficit.
c. Impaired home maintenance.
d. Risk for injury. - Answer-ANS: D
The patient's behaviors support the nursing diagnosis of risk for injury. The patient is
confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury
could result if the patient falls out of bed or begins to bleed from a pulled line.
Nothing in the scenario indicates that this patient lacks knowledge or is at risk for
poisoning. Nothing in the scenario refers to the patient's home maintenance.
A confused patient is restless and continues to try to remove his oxygen and urinary
catheter. What is the priority nursing diagnosis and intervention to implement for this
patient?
a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.
b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary
catheter.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Caregiver role strain: Identify resources to assist with care. - Answer-ANS: A
The priority nursing diagnosis is risk for injury. This patient could cause harm to
himself 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 distraction and providing
companionship or supervision. Patients may be moved to a location closer to the
nurses' station; trained sitters or family members may be involved. Nurses need to
ensure that patients are provided adequate food, liquid, toileting, and relief from pain.
If these and other alternatives fail, this individual may need restraints; in this case, an
order would need to be obtained for the restraint. 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's caregiver is strained.
The patient applies sequential compression devices after going to the bathroom. The
nurse checks the patient's application of the devices and finds that they have been
put on upside down. Which of the following nursing diagnoses will the nurse add to
the patient's plan of care?
a. Risk for poisoning
b. Deficient knowledge
c. Risk for imbalanced body temperature
d. Risk for suffocation - Answer-ANS: B
, The patient needs to understand the purpose of the compression devices and that
proper application is needed for them to be effective. The patient has a knowledge
need and requires instruction regarding the device and its purpose and procedure.
The nurse will intervene by teaching the patient about the sequential compression
device and instructing the patient to call for assistance when getting up to go to the
bathroom in the future, so that the nurse may assist with removal and proper
reapplication. No data support a risk for poisoning, imbalanced body temperature, or
suffocation.
The nurse enters the patient's room and notices a small fire in the headlight above
the patient's bed. Immediately, the nurse assigns a nursing diagnosis of risk for injury
with a goal for the patient to be safe. Which of the following actions should the nurse
take first?
a. Activate the alarm.
b. Extinguish the fire.
c. Remove the patient.
d. Confine the fire. - Answer-ANS: C
Nurses use the mnemonic RACE to set priorities in case of fire. All of these
interventions are necessary, but this patient is in immediate danger with the fire
being over his head and should be rescued and removed from the situation.
The nurse is providing information regarding safety and accidental poisoning to a
grandmother who will be taking custody of a 1-year-old grandchild. Which of the
following comments would indicate that the grandmother needs further instruction?
a. "The number for poison control is 800-222-1222."
b. "Never induce vomiting if my grandchild drinks bleach."
c. "I should call 911 if my grandchild loses consciousness."
d. "If my grandchild eats a plant, I should provide syrup of ipecac." - Answer-ANS: D
Syrup of ipecac to induce vomiting after ingestion of a poison has not been proven
effective in preventing poisoning. This medication should not be administered to the
child. The poison control number is 800-222-1222. After a caustic substance such as
bleach has been drunk, do not induce vomiting. This can cause further burning and
injury as the medication is eliminated. Loss of consciousness associated with
poisoning requires calling 911.
The nurse is teaching a group of older adults at an assisted-living facility about age-
related physiological changes. Which question would be the most important to ask
this group?
a. "Are you able to hear the tornado sirens in your area?"
b. "Are you able to read your favorite book?"
c. "Are you able to remember the name of the person you just met?"
d. "Are you able to open a jar of pickles?" - Answer-ANS: A
The ability to hear safety alerts and seek shelter is imperative to life safety. Although
age-related changes may cause a decrease in sight that affects reading, and
although difficulties in remembering short-term information and opening jars as
arthritis sets in are important to patients and to those caring for them, being able to
hear safety alerts is the priority.
