Final Test Bank Chapter 15 Patient And Resident Safety

Test Generator Questions, Chapter 15, Patient and Resident Safety

Format:  Multiple Choice

Chapter Number:  15

Client Needs:  Safe and Effective Care Environment: Safety and Infection Control

Cognitive Level:  Apply

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  5

Page and Header:  320, Accidents and Incidents in the Health Care Setting

1. The first thing a nursing assistant does when a resident who is being ambulated suddenly begins to fall is to:

A) shout out for the nurse for help with the fall.

B) help manage the fall by guiding the fall.

C) block the resident’s fall with their own body.

D) be careful not to allow the resident to fall on them.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  320, Accidents and Incidents in the Health Care Setting

2. The nursing assistant is caring for a resident who recently received pain medication and is drowsy. The Kardex states to ambulate the resident in the hall twice a day. What action should the nursing assistant take?

A) Ambulate the resident using a gait belt and have the resident hold onto the hall rail as they walk together.

B) Wait a couple of hours for the medication effects to lessen and observe if the resident is alert and able to move safely.

C) Transfer the resident to the chair instead of ambulating the resident down the hall and chart that the resident is drowsy.

D) Skip the second ambulation in the hall because the resident is drowsy.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  6

Page and Header:  320, Accidents and Incidents in the Health Care Setting

3. Which statement(s) is true regarding how a fall should be reported? Select all that apply.

A) Tell the nurse about it immediately.

B) Fill out an incident (occurrence) report.

C) Tell the resident everything will be alright.

D) Explain what happened to the resident’s family.

E) Report the incident directly to the resident’s doctor.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  320, Accidents and Incidents in the Health Care Setting

4. The nursing assistant is caring for a resident who suddenly falls. The assistant establishes which factors that increased the resident’s risk for an accident? Select all that apply. The resident:

A) uses a walker properly.

B) is diagnosed with osteoporosis.

C) received pain medication.

D) forgot to wear their eyeglasses.

E) is 88 years old.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  320, Accidents and Incidents in the Health Care Setting

5. The nursing assistant is bathing the resident diagnosed with diabetes and peripheral neuropathy of their hands, legs, and feet (lack of feeling in those areas). Which factor could place the resident at risk for accidental burns?

A) The resident states the water temperature is just right.

B) The skin is thin and dry in texture.

C) The resident is legally blind.

D) The resident has stiffness in their joints.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  320, Accidents and Incidents in the Health Care Setting

6. The nursing assistant is caring for a new resident who is legally blind. What is the best action for the nursing assistant to take to prevent the resident from falling?

A) Walk with the resident around the new room and describe the environment and where everything is as the resident feels and counts steps.

B) Describe the location of everything as the resident is lying in bed by the direction from the right side or left side or in front of the bed.

C) Encourage the resident to wear slip-resistant soles on their shoes or slippers when walking around in their room.

D) Explain that the resident should call for the nursing assistant any time the resident wants to move around the room.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  328, Restraints and Restraint Alternatives

7. The nursing assistant is caring for several residents who are confused and unsteady on their feet. In which situation does the nursing assistant predict a physician-ordered restraint will be needed?

A) Another nursing assistant called off work, and the assistant has more residents to take care of so it will be difficult to keep the residents safe.

B) The confused resident tried to smoke while in bed by crawling out of bed and getting a pack of cigarettes and a lighter from their closet.

C) The resident needs to remain safe from falling and all other options used have failed to keep the resident safe.

D) The nurse placed the resident by the nursing station and provided activities to distract the resident and the resident is content so far.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  5

Page and Header:  328, Restraints and Restraint Alternatives

8. Which statement is true about applying a vest restraint to the client?

A) Tighten so there is no space between the restraint and the client.

B) Make sure that the restraint is the correct size for the client.

C) Apply the restraint underneath the client’s hospital gown.

D) Secure the restraint to the client’s side rail using a square knot.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  328, Restraints and Restraint Alternatives

9. Guidelines for safe use of restraints require they be completely removed every:

A) day for an hour.

B) evening for 2 hours.

C) hour for 15 minutes.

D) 2 hours for 10 minutes.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  5

Page and Header:   328, Restraints and Restraint Alternatives

10. The nursing assistant covers for another assistant on break. While rounding, the assistant observes a resident wearing a vest restraint with the flaps positioned over each other across the person’s bare chest and there is a flat hand space under the vest and a quick tie knot secured to the bed frame. Which action should the nursing assistant take?

A) Take no action because the vest restraint is properly applied.

B) Loosen the vest restraint and retie it according to the procedure.

C) Retie the quick release knot to the side rail.

D) Have the nurse reapply the vest restraint over the resident’s clothing.

Difficulty: Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  328, Restraints and Restraint Alternatives

11. The nursing assistant is caring for a client after a stroke with right-sided paralysis (unable to move right side of body) who keeps trying to remove their indwelling urinary catheter. What action should the nursing assistant take?

A) Help the nurse to apply a wrist restraint on the left wrist.

B) Help the nurse to apply the mitt restraint on the left hand.

C) Secure the catheter to the right thigh and cover with kerlix.

D) Ask the out-of-state family to take turns sitting with the resident.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  328, Restraints and Restraint Alternatives

12. Which are possible complications of restraint use? Select all that apply.

A) Agitation

B) Increased confusion

C) Weight gain

D) Incontinence

E) Pressure ulcers

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  328, Restraints and Restraint Alternatives

13. When a resident diagnosed with dementia becomes very agitated, the first thing a nursing assistant does is to:

A) ask the nurse for permission to apply a restraint.

B) tell the resident they will have a “time out” in their room.

C) suggest the resident help with paperwork at the nurses’ station.

D) report the behavior to the nurse so a sedative can be given to the resident.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  328, Restraints and Restraint Alternatives

14. Responsibilities of the nursing assistant when caring for a person who is wearing a restraint include: (Select all that apply.)

A) repositioning the person.

B) performing isometric exercises.

C) explaining why the restraint is necessary.

D) checking on the person every 15 minutes.

E) reporting signs of complications immediately.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  328, Restraints and Restraint Alternatives

15. Which could be considered restraints? Select all that apply.

A) Tightly tucked bedsheets

B) Sedating medication

C) Raised side rails

D) A leg brace

E) Mitts

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  328, Restraints and Restraint Alternatives

16. Which observation regarding a client wearing a restraint must be reported immediately?

A) Trouble breathing

B) Decreased agitation

C) The client wants the restraint removed.

D) The client requests to go to the bathroom.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  320, Accidents and Incidents in the Health Care Setting

17. Which action addresses confused residents’ need for distraction and supervision?

A) Having them fold their clothes and put them in their drawers

B) Giving them a snack while watching television in the dayroom

C) Having them sit near the nursing station while sorting papers

D) Asking them to sweep the floor with the cleaning staff

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  328, Restraints and Restraint Alternatives

18. Which is within the nursing assistant’s responsibilities to a resident in restraints?

A) Applying restraints when told to by a registered nurse

B) Documenting any care provided to the resident

C) Checking on the resident every 30 minutes

D) Providing the resident with privacy

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  328, Restraints and Restraint Alternatives

19. When restraints are used before all other methods of control are tried, the staff could be legally guilty of:

A) false imprisonment.

B) poor judgment.

C) heartlessness.

D) libel.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  328, Restraints and Restraint Alternatives

20. The nursing assistant caring for a resident in wrist restraints observes the skin underneath the right restraint is pale, cool to touch, and the nail beds are blue. What action should the nursing assistant take first?

A) Determine if the right wrist restraint is secured by a quick release knot to the bed frame.

B) Loosen the right wrist restraint so two fingers may be easily slipped underneath.

C) Report the observations immediately to the nurse caring for the resident.

D) Remove the right restraint and ask the resident to move the wrist through the range of motion.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  328, Restraints and Restraint Alternatives

21. The nursing assistant asks the RN to check the resident for a possible complication from the chemical restraint when the resident:

A) appears less agitated.

B) refuses to eat their lunch.

C) asks to be taken back to their room.

D) keeps falling asleep in the dayroom.