PN NCLEX EVOLVE: Safety Q's
The nurse is caring for a homebound older postoperative cardiovascular
client. The caregiver's daughter says to the nurse, "My mother has fallen out
of bed three times." Which actions should the nurse reinforce to prevent falls?
Select all that apply. Provide adequate lighting Ensure that frequently used
items are easily accessible, Have the bedside stand and over bed tray table
within reach Rationale: One action is to provide adequate lighting. Ensure that
frequently used items, such as the telephone, eyeglasses, or other personal
belongings, are easily accessible. Place bedside table and overbed table
within reach. Restraints should not be used because they can cause the client
to become more agitated. Leaving both side rails down on the bed of an older
client increases the risk of falling, especially if the client will be reaching
down to obtain a needed item. While caring for a client admitted to the
hospital with suspected seizure activity, the client acknowledges the use of
the herbal supplement ginkgo, to the nurse. Which follow-up questions by the
nurse would be most appropriate? Select all that apply. DO you have a history
of seizure? How long have you been using ginkgo? DO you have a history of
clotting disorder? Have you been diagnosed with diabetes mellitus? Rationale:
Clients with a history of seizures should not use this supplement because it
may increase the frequency of seizure activity. Asking how long the client has
been taking the supplement is an appropriate question. Ginkgo has been
shown to affect clotting time. Diabetics should not use this supplement
because it may affect glucose levels. Ginkgo is taken by mouth; it is not
applied as a cream. The registered nurse (RN) tells a licensed practical nurse
(LPN) that the health care provider has prescribed a hypotonic intravenous
(IV) solution for a client. Which IV solution should the LPN obtain for
administration to the client? 0.45% saline Rationale: Five percent dextrose in
water is an isotonic solution; 10% dextrose in water and 5% dextrose in 0.9%
saline are hypertonic solutions; 0.45% saline is hypotonic and is probably the
only hypotonic solution used in clinical situations. Distilled water is another
example of a hypotonic solution. Hypotonic solutions contain a lower
concentration of salt or more water than an isotonic solution. The nurse is
preparing to suction a client through a tracheostomy tube. The nurse should
avoid which action when performing this procedure? Placing suction on the
catheter while introducing the catheter into the tracheostomy tube Rationale:
Suction is not placed on the catheter when the catheter is introduced into the
tracheostomy tube. Suction draws out oxygen, and placing suction on the
catheter at this time could traumatize tracheal tissue. The remaining options
are appropriate components of the plan of care for suctioning. The nurse
administers an injection to a client with a diagnosis of acquired
immunodeficiency syndrome (AIDS). After administering the medication, the
nurse should dispose of the used needle by which method? Placing the
needle and syringe in a puncture-resistant container Rationale: The correct
procedure for needle disposal is to discard uncapped needles and sharps in a
hard-walled, puncture-resistant, leak-proof container immediately after use.
Discarding the uncapped needle and attached syringe in a designated sharps
, container prevents injury to the client and health care personnel. Recapping
needles increases the risk of needle-stick injury. Options 1, 3, and 4 are
unsafe actions. The nurse is providing instructions to the mother of a toddler
regarding safety measures in the home to prevent an accidental burn injury.
Which statement by the mother indicates a need for further teaching? I need
to be sure to place my cup of coffee on the counter Rationale: Toddlers, with
their increased mobility and developing motor skills, can reach hot water,
open fires, or hot objects placed on counters and stoves above their eye level.
Parents should be encouraged to remain in the kitchen when preparing a
meal and reminded to use the back burners on the stove and to turn pot
handles inward and toward the middle of the stove. Hot liquids should never
be left unattended, and the toddler should always be supervised. Option 3
does not reflect an adequate understanding of the principles of safety. The
nurse is caring for a client who becomes agitated and begins to pull on a
surgically placed abdominal drainage tube. The health care provider visits
and prescribes restraints if needed. Which action is appropriate to delegate
to the unlicensed assistive personnel (UAP), who has completed the facility's
education about care of the restrained client? Select all that apply. Socialize
with the restrained client. Remove the restraint and perform range of motion
activity Reapply the restraint after assisting the client to the bathroom
Rationale: The skill of applying restraints can be delegated to the UAP whom
the nurse knows is competent in caring for a client with restraints. The nurse
is responsible to document the mental status of the client necessitating the
restraints. The nurse must determine the appropriate type of restraint and
frequency of position change. The UAP may perform care including meeting
mobility, hydration, nutrition, elimination, and socialization needs and
removing and reapplying restraints under the direction of the nurse. The
nurse is working in a long-term care facility and is observing a new
unlicensed assistive personnel (UAP) caring for a client who requires a
security device (wrist restraints). The nurse determines that the nursing
assistant is providing safe care if the nurse observes the UAP checking skin
integrity by completely removing the client's wrist restraints at which time
interval? Every 2 hours Rationale: Restraints should be completely removed
for a brief period at least every 2 hours, and this action should be
documented in the nurse's notes. The color of the extremity should be noted,
and the pulse should be assessed. The client should be asked to move the
extremity, or range-of-motion exercises should be performed. Agency
guidelines regarding the use of restraints should always be followed. A client
with chronic pain has been taught how to operate a transcutaneous electrical
nerve stimulation (TENS) unit. Which action by the client shows
understanding of the appropriate use of the device when the level of
stimulation is uncomfortable? The client adjust the setting downward slightly.
Rationale: The client applies a transcutaneous electrical nerve stimulation
unit by placing two electrodes on the skin and adjusting the level of
stimulation to one lead at a time. The amount of stimulation is increased until
the client feels discomfort, which indicates that the maximal stimulation
necessary to block painful stimuli has been reached. The volume is then
reduced slightly until no further discomfort occurs. The other options are
The nurse is caring for a homebound older postoperative cardiovascular
client. The caregiver's daughter says to the nurse, "My mother has fallen out
of bed three times." Which actions should the nurse reinforce to prevent falls?
Select all that apply. Provide adequate lighting Ensure that frequently used
items are easily accessible, Have the bedside stand and over bed tray table
within reach Rationale: One action is to provide adequate lighting. Ensure that
frequently used items, such as the telephone, eyeglasses, or other personal
belongings, are easily accessible. Place bedside table and overbed table
within reach. Restraints should not be used because they can cause the client
to become more agitated. Leaving both side rails down on the bed of an older
client increases the risk of falling, especially if the client will be reaching
down to obtain a needed item. While caring for a client admitted to the
hospital with suspected seizure activity, the client acknowledges the use of
the herbal supplement ginkgo, to the nurse. Which follow-up questions by the
nurse would be most appropriate? Select all that apply. DO you have a history
of seizure? How long have you been using ginkgo? DO you have a history of
clotting disorder? Have you been diagnosed with diabetes mellitus? Rationale:
Clients with a history of seizures should not use this supplement because it
may increase the frequency of seizure activity. Asking how long the client has
been taking the supplement is an appropriate question. Ginkgo has been
shown to affect clotting time. Diabetics should not use this supplement
because it may affect glucose levels. Ginkgo is taken by mouth; it is not
applied as a cream. The registered nurse (RN) tells a licensed practical nurse
(LPN) that the health care provider has prescribed a hypotonic intravenous
(IV) solution for a client. Which IV solution should the LPN obtain for
administration to the client? 0.45% saline Rationale: Five percent dextrose in
water is an isotonic solution; 10% dextrose in water and 5% dextrose in 0.9%
saline are hypertonic solutions; 0.45% saline is hypotonic and is probably the
only hypotonic solution used in clinical situations. Distilled water is another
example of a hypotonic solution. Hypotonic solutions contain a lower
concentration of salt or more water than an isotonic solution. The nurse is
preparing to suction a client through a tracheostomy tube. The nurse should
avoid which action when performing this procedure? Placing suction on the
catheter while introducing the catheter into the tracheostomy tube Rationale:
Suction is not placed on the catheter when the catheter is introduced into the
tracheostomy tube. Suction draws out oxygen, and placing suction on the
catheter at this time could traumatize tracheal tissue. The remaining options
are appropriate components of the plan of care for suctioning. The nurse
administers an injection to a client with a diagnosis of acquired
immunodeficiency syndrome (AIDS). After administering the medication, the
nurse should dispose of the used needle by which method? Placing the
needle and syringe in a puncture-resistant container Rationale: The correct
procedure for needle disposal is to discard uncapped needles and sharps in a
hard-walled, puncture-resistant, leak-proof container immediately after use.
Discarding the uncapped needle and attached syringe in a designated sharps
, container prevents injury to the client and health care personnel. Recapping
needles increases the risk of needle-stick injury. Options 1, 3, and 4 are
unsafe actions. The nurse is providing instructions to the mother of a toddler
regarding safety measures in the home to prevent an accidental burn injury.
Which statement by the mother indicates a need for further teaching? I need
to be sure to place my cup of coffee on the counter Rationale: Toddlers, with
their increased mobility and developing motor skills, can reach hot water,
open fires, or hot objects placed on counters and stoves above their eye level.
Parents should be encouraged to remain in the kitchen when preparing a
meal and reminded to use the back burners on the stove and to turn pot
handles inward and toward the middle of the stove. Hot liquids should never
be left unattended, and the toddler should always be supervised. Option 3
does not reflect an adequate understanding of the principles of safety. The
nurse is caring for a client who becomes agitated and begins to pull on a
surgically placed abdominal drainage tube. The health care provider visits
and prescribes restraints if needed. Which action is appropriate to delegate
to the unlicensed assistive personnel (UAP), who has completed the facility's
education about care of the restrained client? Select all that apply. Socialize
with the restrained client. Remove the restraint and perform range of motion
activity Reapply the restraint after assisting the client to the bathroom
Rationale: The skill of applying restraints can be delegated to the UAP whom
the nurse knows is competent in caring for a client with restraints. The nurse
is responsible to document the mental status of the client necessitating the
restraints. The nurse must determine the appropriate type of restraint and
frequency of position change. The UAP may perform care including meeting
mobility, hydration, nutrition, elimination, and socialization needs and
removing and reapplying restraints under the direction of the nurse. The
nurse is working in a long-term care facility and is observing a new
unlicensed assistive personnel (UAP) caring for a client who requires a
security device (wrist restraints). The nurse determines that the nursing
assistant is providing safe care if the nurse observes the UAP checking skin
integrity by completely removing the client's wrist restraints at which time
interval? Every 2 hours Rationale: Restraints should be completely removed
for a brief period at least every 2 hours, and this action should be
documented in the nurse's notes. The color of the extremity should be noted,
and the pulse should be assessed. The client should be asked to move the
extremity, or range-of-motion exercises should be performed. Agency
guidelines regarding the use of restraints should always be followed. A client
with chronic pain has been taught how to operate a transcutaneous electrical
nerve stimulation (TENS) unit. Which action by the client shows
understanding of the appropriate use of the device when the level of
stimulation is uncomfortable? The client adjust the setting downward slightly.
Rationale: The client applies a transcutaneous electrical nerve stimulation
unit by placing two electrodes on the skin and adjusting the level of
stimulation to one lead at a time. The amount of stimulation is increased until
the client feels discomfort, which indicates that the maximal stimulation
necessary to block painful stimuli has been reached. The volume is then
reduced slightly until no further discomfort occurs. The other options are
