Chapter 23 Safety

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis?
1)
Risk for Falls

2)
Risk for Ineffective Airway Clearance (choking) 3)
Risk for Poisoning
4)
Risk for Suffocation (drowning)

TB23-1

ANS: 1
Loss of muscle strength and joint mobility place older adults at risk for falls. Choking, drowning, and ingesting poisons are primary safety concerns for infants and toddlers.

PTS: 1 DIF: Moderate REF: p. 653
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall

____ 2. A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be slightly unsteady. What assessment should the nurse perform next?
1)

Perform the Get Up and Go Test.
2)
Ask the patient if he has fallen in the past year.
3)
Refer the patient for a comprehensive fall evaluation. 4)
Administer the Timed Up and Go Test.

ANS: 2
If a patient’s gait or balance is unsteady, the nurse should question the patient for a history of falls. If the patient reports a single fall, the nurse should do the Get Up and Go Test. If the patient has difficulty with that test, or is unsteady with it, the nurse should perform a follow-up assessment of gait and balance by having the person close the eyes for a few seconds wile standing in place; stand with eyes closed while the nurse pushes gently on the sternum; walk, stop, turn around, return to the chair, and sit in the chair without using his arms for support. Physicians and advanced practitioners perform the Timed Up and Go Test; it is recommended annually for patients 65 years or older.

Treas Fundamentals TB23-2 Test Bank, Chapter 23

PTS: 1 DIF: Difficult REF: p. 661
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application

____ 3. The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best?
1)
Continue to monitor the pump to see if the crack worsens.

2)
Place the pump back on the utility room shelf.
3)
A small crack poses no danger so continue using the pump. 4)
Clearly label the pump and send it for repair.

ANS: 4
Whenever an electrical safety hazard is suspected or visible, the nurse should label the malfunctioning equipment and send it for repair or inspection. Continuing to use the IV infusion pump or any other equipment places the patient at risk for injury. Placing the pump back on the shelf places other healthcare team members at risk for electrical injury if they attempt to use the equipment.

PTS: 1 DIF: Easy REF: p. 673
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

____ 4. A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first?
1)

Apply a cloth vest restraint.
2)
Encourage a family member to stay with the patient. 3)
Administer lorazepam (an antianxiety medication). 4)
Keep the patient’s bed side rails up.

ANS: 2
The nurse should use one-to-one supervision with this patient to maintain the patient’s safety. One way to accomplish this is by encouraging a family member to stay with the patient. Restraints should be used only when all other less-restrictive measures have failed and are absolutely necessary to prevent injury to the patient. Restraints have been shown to jeopardize patient safety. It is not appropriate to administer sedation for the

Treas Fundamentals TB23-3 Test Bank, Chapter 23

purpose of keeping the patient in bed; this is a form of restraint. Keeping the side rails up is also a form of restraint and increases the risk for falling.

PTS: 1 DIF: Moderate REF: p. 673
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application