Nursing: A Concept-Based Approach to Learning, 2e (Pearson)

Module 51 Safety

The Concept of Safety

1) The nurse is caring for a client who is prone to falls. Which nursing diagnosis would be most
appropriate for this client?
A) Risk for Injury
B) Risk for Suffocation
C) Deficient Knowledge
D) Risk for Disuse Syndrome
Answer: A
Explanation:
A) Risk for Injury is a state in which the individual is at risk as a result of environmental
conditions such as a fall. Deficient Knowledge deals with injury prevention. Risk for Disuse
Syndrome is a deterioration of a body system as the result of prescribed or unavoidable
musculoskeletal inactivity. Risk for Suffocation occurs when inadequate air is available for
inhalation.
B) Risk for Injury is a state in which the individual is at risk as a result of environmental
conditions such as a fall. Deficient Knowledge deals with injury prevention. Risk for Disuse
Syndrome is a deterioration of a body system as the result of prescribed or unavoidable
musculoskeletal inactivity. Risk for Suffocation occurs when inadequate air is available for
inhalation.
C) Risk for Injury is a state in which the individual is at risk as a result of environmental
conditions such as a fall. Deficient Knowledge deals with injury prevention. Risk for Disuse
Syndrome is a deterioration of a body system as the result of prescribed or unavoidable
musculoskeletal inactivity. Risk for Suffocation occurs when inadequate air is available for
inhalation.
D) Risk for Injury is a state in which the individual is at risk as a result of environmental
conditions such as a fall. Deficient Knowledge deals with injury prevention. Risk for Disuse
Syndrome is a deterioration of a body system as the result of prescribed or unavoidable
musculoskeletal inactivity. Risk for Suffocation occurs when inadequate air is available for
inhalation.
Page Ref: 2695
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Planning
Learning Outcome: 2. Identify appropriate nursing diagnoses for the client with potential risks
for injury.

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2) A nurse manager is assessing the hospital environment in order to decrease the risk for client
falls. Which is the best intervention to decrease the risk of client falls?
A) Keep the call button within reach at all times.
B) Read label directions.
C) Keep electrical cords under the bed.
D) Clean the environment of clutter.
Answer: D
Explanation:
A) Keeping the environment tidy and free of clutter will go a long way in preventing falls. The
call button should always be within reach of the client, but is not the best way to prevent falls.
Electrical cords should be used only if necessary, and the maintenance department can help if
any of them present a hazard. Reading label directions will prevent the wrong use of substances
given to the client but would not directly prevent falls.
B) Keeping the environment tidy and free of clutter will go a long way in preventing falls. The
call button should always be within reach of the client, but is not the best way to prevent falls.
Electrical cords should be used only if necessary, and the maintenance department can help if
any of them present a hazard. Reading label directions will prevent the wrong use of substances
given to the client but would not directly prevent falls.
C) Keeping the environment tidy and free of clutter will go a long way in preventing falls. The
call button should always be within reach of the client, but is not the best way to prevent falls.
Electrical cords should be used only if necessary, and the maintenance department can help if
any of them present a hazard. Reading label directions will prevent the wrong use of substances
given to the client but would not directly prevent falls.
D) Keeping the environment tidy and free of clutter will go a long way in preventing falls. The
call button should always be within reach of the client, but is not the best way to prevent falls.
Electrical cords should be used only if necessary, and the maintenance department can help if
any of them present a hazard. Reading label directions will prevent the wrong use of substances
given to the client but would not directly prevent falls.
Page Ref: 2703-2704
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 3. Describe nursing interventions to reduce the client's risk of injury.

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3) A client in the intensive care unit is combative and pulling at the endotracheal tube, which
must remain in place. After applying soft hand restraints to protect the client's airway, which
action should the nurse take next?
A) Notify the physician.
B) Notify the family of the need for restraints.
C) Reassess the need for the restraints in 8 hours.
D) Document the application of restraints in the chart.
Answer: A
Explanation:
A) According to the law, the physician must see the client and write an order within 1 hour of
application of restraints. The nurse would apply the restraints to protect the airway and then
immediately notify the physician. The nurse would notify the family if present, but that is not the
legal priority. The nurse would document the use of restraints as soon as possible after notifying
the physician. Most agencies require reassessment of need every 1-2 hours.
B) According to the law, the physician must see the client and write an order within 1 hour of
application of restraints. The nurse would apply the restraints to protect the airway and then
immediately notify the physician. The nurse would notify the family if present, but that is not the
legal priority. The nurse would document the use of restraints as soon as possible after notifying
the physician. Most agencies require reassessment of need every 1-2 hours.
C) According to the law, the physician must see the client and write an order within 1 hour of
application of restraints. The nurse would apply the restraints to protect the airway and then
immediately notify the physician. The nurse would notify the family if present, but that is not the
legal priority. The nurse would document the use of restraints as soon as possible after notifying
the physician. Most agencies require reassessment of need every 1-2 hours.
D) According to the law, the physician must see the client and write an order within 1 hour of
application of restraints. The nurse would apply the restraints to protect the airway and then
immediately notify the physician. The nurse would notify the family if present, but that is not the
legal priority. The nurse would document the use of restraints as soon as possible after notifying
the physician. Most agencies require reassessment of need every 1-2 hours.
Page Ref: 2704
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 4. Describe the indications for and legal implications of the use of chemical
and physical restraints.

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4) A client asks the nurse if the staff members make many mistakes because there are so many
posters and signs about safety on the walls. What should the nurse respond to this client?
A) "We want the public to know we are trying to be safe."
B) "Clinic staff members require frequent reminders about client safety."
C) "National safety goals focus on the individual making the error."
D) "National safety goals seek prevention of injury."
Answer: D
Explanation:
A) National Patient Safety Goals are focused on solutions to safety issues and prevention of
further injuries. Instead of focusing on the individual who made the error, the goals focus on
finding ways to prevent that error from happening again. The staff members should not need to
be reminded about safety, as safety should be the culture of health care. Healthcare agencies
want the public to know about their safety promotions, but that is not the goal of the program.
B) National Patient Safety Goals are focused on solutions to safety issues and prevention of
further injuries. Instead of focusing on the individual who made the error, the goals focus on
finding ways to prevent that error from happening again. The staff members should not need to
be reminded about safety, as safety should be the culture of health care. Healthcare agencies
want the public to know about their safety promotions, but that is not the goal of the program.
C) National Patient Safety Goals are focused on solutions to safety issues and prevention of
further injuries. Instead of focusing on the individual who made the error, the goals focus on
finding ways to prevent that error from happening again. The staff members should not need to
be reminded about safety, as safety should be the culture of health care. Healthcare agencies
want the public to know about their safety promotions, but that is not the goal of the program.
D) National Patient Safety Goals are focused on solutions to safety issues and prevention of
further injuries. Instead of focusing on the individual who made the error, the goals focus on
finding ways to prevent that error from happening again. The staff members should not need to
be reminded about safety, as safety should be the culture of health care. Healthcare agencies
want the public to know about their safety promotions, but that is not the goal of the program.
Page Ref: 2701
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 5. Explain the purpose of National Patient Safety Goals.

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5) Several nurses are discussing the Joint Commission's 2013 National Patient Safety Goals
during a staff meeting. Which goal improves the effectiveness of communication among
caregivers?
A) Conduct a verification process to confirm the correct procedure.
B) Transmit test results in a timely manner to the appropriate staff member.
C) Review a list of look-alike/sound-alike drugs used in the organization.
D) Use the client's room number as an identifier.
Answer: B
Explanation:
A) Transmitting test results in a timely manner to the appropriate staff member improves the
effectiveness of communication among caregivers. Using the client's room number as an
identifier is a passive technique that would not improve the accuracy of client identification.
Conducting a verification process to confirm that the correct procedure for the correct client is to
be performed is a way of improving the accuracy of client identification. Annually reviewing a
list of look-alike/sound-alike drugs is done to improve the safety of use of medication in an
organization, not to improve effective communication.
B) Transmitting test results in a timely manner to the appropriate staff member improves the
effectiveness of communication among caregivers. Using the client's room number as an
identifier is a passive technique that would not improve the accuracy of client identification.
Conducting a verification process to confirm that the correct procedure for the correct client is to
be performed is a way of improving the accuracy of client identification. Annually reviewing a
list of look-alike/sound-alike drugs is done to improve the safety of use of medication in an
organization, not to improve effective communication.
C) Transmitting test results in a timely manner to the appropriate staff member improves the
effectiveness of communication among caregivers. Using the client's room number as an
identifier is a passive technique that would not improve the accuracy of client identification.
Conducting a verification process to confirm that the correct procedure for the correct client is to
be performed is a way of improving the accuracy of client identification. Annually reviewing a
list of look-alike/sound-alike drugs is done to improve the safety of use of medication in an
organization, not to improve effective communication.
D) Transmitting test results in a timely manner to the appropriate staff member improves the
effectiveness of communication among caregivers. Using the client's room number as an
identifier is a passive technique that would not improve the accuracy of client identification.
Conducting a verification process to confirm that the correct procedure for the correct client is to
be performed is a way of improving the accuracy of client identification. Annually reviewing a
list of look-alike/sound-alike drugs is done to improve the safety of use of medication in an
organization, not to improve effective communication.
Page Ref: 2701
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Nursing Process: Assessment
Learning Outcome: 5. Explain the purpose of National Patient Safety Goals.

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6) After completing an assessment, the nurse determines a client is at risk for safety issues. What
did the nurse assess in this client?
Select all that apply.
A) Lives with adult married daughter and family
B) Occasional dizziness with walking
C) Prescribed antihypertensive and pain medication
D) Ingests three meals a day and two snacks
E) Receives an annual ophthalmologic examination
Answer: B, C
Explanation:
A) Nurses consider safety at all points during the nursing process, and while working to
prioritize client needs. Risks to safety include medications that could cause adverse effects such
as antihypertensives and pain medication and factors that can impact falls such as mobility issues
or balance. Living with family, eating a balanced diet, and having annual eye examinations do
not increase the client's risk for safety issues.
B) Nurses consider safety at all points during the nursing process, and while working to prioritize
client needs. Risks to safety include medications that could cause adverse effects such as
antihypertensives and pain medication and factors that can impact falls such as mobility issues or
balance. Living with family, eating a balanced diet, and having annual eye examinations do not
increase the client's risk for safety issues.
C) Nurses consider safety at all points during the nursing process, and while working to prioritize
client needs. Risks to safety include medications that could cause adverse effects such as
antihypertensives and pain medication and factors that can impact falls such as mobility issues or
balance. Living with family, eating a balanced diet, and having annual eye examinations do not
increase the client's risk for safety issues.
D) Nurses consider safety at all points during the nursing process, and while working to
prioritize client needs. Risks to safety include medications that could cause adverse effects such
as antihypertensives and pain medication and factors that can impact falls such as mobility issues
or balance. Living with family, eating a balanced diet, and having annual eye examinations do
not increase the client's risk for safety issues.
E) Nurses consider safety at all points during the nursing process, and while working to prioritize
client needs. Risks to safety include medications that could cause adverse effects such as
antihypertensives and pain medication and factors that can impact falls such as mobility issues or
balance. Living with family, eating a balanced diet, and having annual eye examinations do not
increase the client's risk for safety issues.
Page Ref: 2703
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Nursing Process: Assessment
Learning Outcome: 1. Describe the principle criteria included in a client safety assessment.

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7) The instructor is evaluating a staff nurse's knowledge, skills, and attitudes when addressing
safety issues with client care. What observations indicate the nurse is skilled when addressing
safety concerns?
Select all that apply.
A) Documents care immediately after providing it
B) Devises methods that enhance teamwork
C) Participates in conflict resolution
D) Recognizes deficiencies between current and best practice
E) Participates in root cause analysis when appropriate
Answer: A, E
Explanation:
A) Skills associated with safety include establishing ways to decrease dependence on memory
such as documenting care immediately after providing it and undertaking root cause analysis
instead of assigning blame. Devising methods that enhance teamwork and participating in
conflict resolution are skills associated with teamwork and collaboration. Recognizing
deficiencies between current and best practice is a skill associated with quality improvement.
B) Skills associated with safety include establishing ways to decrease dependence on memory
such as documenting care immediately after providing it and undertaking root cause analysis
instead of assigning blame. Devising methods that enhance teamwork and participating in
conflict resolution are skills associated with teamwork and collaboration. Recognizing
deficiencies between current and best practice is a skill associated with quality improvement.
C) Skills associated with safety include establishing ways to decrease dependence on memory
such as documenting care immediately after providing it and undertaking root cause analysis
instead of assigning blame. Devising methods that enhance teamwork and participating in
conflict resolution are skills associated with teamwork and collaboration. Recognizing
deficiencies between current and best practice is a skill associated with quality improvement.
D) Skills associated with safety include establishing ways to decrease dependence on memory
such as documenting care immediately after providing it and undertaking root cause analysis
instead of assigning blame. Devising methods that enhance teamwork and participating in
conflict resolution are skills associated with teamwork and collaboration. Recognizing
deficiencies between current and best practice is a skill associated with quality improvement.
E) Skills associated with safety include establishing ways to decrease dependence on memory
such as documenting care immediately after providing it and undertaking root cause analysis
instead of assigning blame. Devising methods that enhance teamwork and participating in
conflict resolution are skills associated with teamwork and collaboration. Recognizing
deficiencies between current and best practice is a skill associated with quality improvement.
Page Ref: 2707
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Nursing Process: Evaluation
Learning Outcome: 6. Analyze QSEN and KSA competencies and explain their application to
client care.

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8) The nurse is developing a plan of care for a client who is at risk for falls. Which interventions
would be appropriate for the nurse to include in the plan of care?
Select all that apply.
A) Apply physical restraints if the client gets out of bed.
B) Assess the client's vision and make sure he is utilizing any prescribed eyewear.
C) Utilize side rails on client beds.
D) Keep frequently used items within easy reach.
Answer: B, C, D
Explanation:
A) Assessing the client's vision and making sure he is utilizing any prescribed eyewear is an
appropriate action. Poor and blurry vision increases the client's risk of falling. Utilizing side rails
on the client bed to prevent falls while the client is sleeping is an appropriate intervention.
Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to
prevent falls. It is not appropriate for the nurse to apply physical restraints if client gets out of
bed. The nurse could include in the plan of care to apply physical restraints only when absolutely
necessary for the client's safety and only by physician's order.
B) Assessing the client's vision and making sure he is utilizing any prescribed eyewear is an
appropriate action. Poor and blurry vision increases the client's risk of falling. Utilizing side rails
on the client bed to prevent falls while the client is sleeping is an appropriate intervention.
Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to
prevent falls. It is not appropriate for the nurse to apply physical restraints if client gets out of
bed. The nurse could include in the plan of care to apply physical restraints only when absolutely
necessary for the client's safety and only by physician's order.
C) Assessing the client's vision and making sure he is utilizing any prescribed eyewear is an
appropriate action. Poor and blurry vision increases the client's risk of falling. Utilizing side rails
on the client bed to prevent falls while the client is sleeping is an appropriate intervention.
Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to
prevent falls. It is not appropriate for the nurse to apply physical restraints if client gets out of
bed. The nurse could include in the plan of care to apply physical restraints only when absolutely
necessary for the client's safety and only by physician's order.
D) Assessing the client's vision and making sure he is utilizing any prescribed eyewear is an
appropriate action. Poor and blurry vision increases the client's risk of falling. Utilizing side rails
on the client bed to prevent falls while the client is sleeping is an appropriate intervention.
Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to
prevent falls. It is not appropriate for the nurse to apply physical restraints if client gets out of
bed. The nurse could include in the plan of care to apply physical restraints only when absolutely
necessary for the client's safety and only by physician's order.
Page Ref: 2703-2704
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
Nursing Process: Planning
Learning Outcome: 3. Describe nursing interventions that reduce the client's risk for injury.

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9) The nurse educator in the hospital is educating a newly licensed nurse on National Patient
Safety Goals. When discussing the goal of safe medicine use, the nurse educator is aware that
which is of the following is not a solution to safe medicine use?
A) Labeling all medicines that will be administered to the client appropriately
B) Using extra caution with blood thinners
C) Taking care when recording client medicine information
D) Allowing the client to keep home meds at the bedside for use while in the hospital
Answer: D
Explanation:
A) Safe medicine use is identified as one of the National Patient Safety Goals for hospitals.
Solutions to better reach the goal of safe medicine include labeling all medicines, using extra
caution with blood thinners, and taking care when recording and communicating client medicine
information. It is not appropriate to allow the client to keep home medication at the bedside for
use in the hospital.
B) Safe medicine use is identified as one of the National Patient Safety Goals for hospitals.
Solutions to better reach the goal of safe medicine include labeling all medicines, using extra
caution with blood thinners, and taking care when recording and communicating client medicine
information. It is not appropriate to allow the client to keep home medication at the bedside for
use in the hospital.
C) Safe medicine use is identified as one of the National Patient Safety Goals for hospitals.
Solutions to better reach the goal of safe medicine include labeling all medicines, using extra
caution with blood thinners, and taking care when recording and communicating client medicine
information. It is not appropriate to allow the client to keep home medication at the bedside for
use in the hospital.
D) Safe medicine use is identified as one of the National Patient Safety Goals for hospitals.
Solutions to better reach the goal of safe medicine include labeling all medicines, using extra
caution with blood thinners, and taking care when recording and communicating client medicine
information. It is not appropriate to allow the client to keep home medication at the bedside for
use in the hospital.
Page Ref: 2701
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
Nursing Process: Teaching and Learning
Learning Outcome: 5. Explain the purpose of National Patient Safety Goals.

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Exemplar 51.1 Safety Considerations Across the Life Span

1) The nurse is conducting a class for a group of pregnant clients. Which topics should the nurse
include when teaching this group about safety of the fetus?
A) Pedestrian accidents
B) Suffocation in the crib
C) Alcohol consumption
D) Drowning
Answer: C
Explanation:
A) Alcohol consumption is a safety hazard for the fetus, and pregnant women should be educated
about the importance of not drinking alcoholic beverages while pregnant. Suffocation in the crib
is a safety hazard for both newborns and infants. Drowning is seen in toddlers and preschoolers,
and pedestrian accidents are seen in the older adult.
B) Alcohol consumption is a safety hazard for the fetus, and pregnant women should be educated
about the importance of not drinking alcoholic beverages while pregnant. Suffocation in the crib
is a safety hazard for both newborns and infants. Drowning is seen in toddlers and preschoolers,
and pedestrian accidents are seen in the older adult.
C) Alcohol consumption is a safety hazard for the fetus, and pregnant women should be educated
about the importance of not drinking alcoholic beverages while pregnant. Suffocation in the crib
is a safety hazard for both newborns and infants. Drowning is seen in toddlers and preschoolers,
and pedestrian accidents are seen in the older adult.
D) Alcohol consumption is a safety hazard for the fetus, and pregnant women should be educated
about the importance of not drinking alcoholic beverages while pregnant. Suffocation in the crib
is a safety hazard for both newborns and infants. Drowning is seen in toddlers and preschoolers,
and pedestrian accidents are seen in the older adult.
Page Ref: 2708-2709
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 4. Demonstrate client teaching aimed at reducing the risk of injury or
illness.

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2) A nurse conducted a class on fall prevention for a group of elderly clients in the community.
Which observation during a client home visit indicates that teaching on fall prevention was
effective?
A) All meat is placed in the freezer.
B) The locks were changed on the doors.
C) Scatter rugs are placed in the kitchen.
D) Safety strips are installed in the shower.
Answer: D
Explanation:
A) Safety strips in the shower can prevent falls. The client who installs the strips has understood
the nurse's teaching. Changing the locks may promote safety if there have been frequent break-
ins, but there is no evidence of that. Scatter rugs in any area of the home are a safety hazard. The
nurse encourages the client to place perishable foods in the refrigerator when arriving home from
the store.
B) Safety strips in the shower can prevent falls. The client who installs the strips has understood
the nurse's teaching. Changing the locks may promote safety if there have been frequent break-
ins, but there is no evidence of that. Scatter rugs in any area of the home are a safety hazard. The
nurse encourages the client to place perishable foods in the refrigerator when arriving home from
the store.
C) Safety strips in the shower can prevent falls. The client who installs the strips has understood
the nurse's teaching. Changing the locks may promote safety if there have been frequent break-
ins, but there is no evidence of that. Scatter rugs in any area of the home are a safety hazard. The
nurse encourages the client to place perishable foods in the refrigerator when arriving home from
the store.
D) Safety strips in the shower can prevent falls. The client who installs the strips has understood
the nurse's teaching. Changing the locks may promote safety if there have been frequent break-
ins, but there is no evidence of that. Scatter rugs in any area of the home are a safety hazard. The
nurse encourages the client to place perishable foods in the refrigerator when arriving home from
the store.
Page Ref: 2703-2704
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Nursing Process: Evaluation
Learning Outcome: 4. Demonstrate client teaching aimed at reducing the risk of injury or
illness.

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3) A home health nurse is teaching an older client who has returned home after discharge from
the hospital about injury prevention. Which outcomes and goals would be appropriate to include
in this client's plan of care?
A) The client will take his medication as desired.
B) The client will make uninformed choices when addressing health issues.
C) The client will demonstrate an understanding of all limitations.
D) The client will establish a buddy system.
Answer: D
Explanation:
A) Establishing a buddy system provides social contact, safeguards against abuse, and offers
respite for caregivers. It also provides a way for elders to be checked up on daily. The client may
resent imposed limitations and act out in such a way as to cause injury. Making uninformed
choices about one's health could be unsafe instead of safe to the client. A routine should be
established for medication administration with correct dosage to prevent the possibility of
overdose toxicity.
B) Establishing a buddy system provides social contact, safeguards against abuse, and offers
respite for caregivers. It also provides a way for elders to be checked up on daily. The client may
resent imposed limitations and act out in such a way as to cause injury. Making uninformed
choices about one's health could be unsafe instead of safe to the client. A routine should be
established for medication administration with correct dosage to prevent the possibility of
overdose toxicity.
C) Establishing a buddy system provides social contact, safeguards against abuse, and offers
respite for caregivers. It also provides a way for elders to be checked up on daily. The client may
resent imposed limitations and act out in such a way as to cause injury. Making uninformed
choices about one's health could be unsafe instead of safe to the client. A routine should be
established for medication administration with correct dosage to prevent the possibility of
overdose toxicity.
D) Establishing a buddy system provides social contact, safeguards against abuse, and offers
respite for caregivers. It also provides a way for elders to be checked up on daily. The client may
resent imposed limitations and act out in such a way as to cause injury. Making uninformed
choices about one's health could be unsafe instead of safe to the client. A routine should be
established for medication administration with correct dosage to prevent the possibility of
overdose toxicity.
Page Ref: 2708
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Nursing Process: Planning
Learning Outcome: 1. Develop a nursing plan of care aimed at preventing injury and illness.

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4) The nurse is visiting a family in the home to conduct a risk assessment. The family has a
toddler and a preschool-aged child. What would be considered a safety hazard?
A) Safety plugs in electrical outlets
B) Medications on the kitchen counter
C) Lack of helmets next to bicycles
D) Deadbolt locks on the doors
Answer: B
Explanation:
A) The nurse would instruct the parents to keep medications out of the children's reach.
Medication poisoning happens easily with young toddlers and preschool-age children who think
the medication is candy. Safety plugs are appropriate for this age group. Deadbolt locks are
appropriate to keep toddlers from wandering out to the street. A lack of a helmet next to a bike
does not mean there are no helmets in the house. This finding would cause the nurse to ask more
questions but is not considered a definite safety risk.
B) The nurse would instruct the parents to keep medications out of the children's reach.
Medication poisoning happens easily with young toddlers and preschool-age children who think
the medication is candy. Safety plugs are appropriate for this age group. Deadbolt locks are
appropriate to keep toddlers from wandering out to the street. A lack of a helmet next to a bike
does not mean there are no helmets in the house. This finding would cause the nurse to ask more
questions but is not considered a definite safety risk.
C) The nurse would instruct the parents to keep medications out of the children's reach.
Medication poisoning happens easily with young toddlers and preschool-age children who think
the medication is candy. Safety plugs are appropriate for this age group. Deadbolt locks are
appropriate to keep toddlers from wandering out to the street. A lack of a helmet next to a bike
does not mean there are no helmets in the house. This finding would cause the nurse to ask more
questions but is not considered a definite safety risk.
D) The nurse would instruct the parents to keep medications out of the children's reach.
Medication poisoning happens easily with young toddlers and preschool-age children who think
the medication is candy. Safety plugs are appropriate for this age group. Deadbolt locks are
appropriate to keep toddlers from wandering out to the street. A lack of a helmet next to a bike
does not mean there are no helmets in the house. This finding would cause the nurse to ask more
questions but is not considered a definite safety risk.
Page Ref: 2710-2711
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Nursing Process: Assessment
Learning Outcome: 2. Conduct a risk assessment.

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5) The nurse is conducting a home safety class for a group of parents in the community. Which
should the nurse teach families that would contribute to maintaining safety in the home?
A) Remove labels from containers and refill for recycling.
B) Use overloaded outlets only when necessary.
C) Keep plants in the home.
D) Always pull a plug at the plug-in from the wall outlet.
Answer: D
Explanation:
A) Always pull a plug at the plug-in from the wall outlet. Pulling a plug by its cord can damage
the cord and plug unit, creating a dangerous situation. Not knowing which plants are poisonous
and which are not may pose a serious problem for children in the home. Always avoid
overloading outlets at any time because it may damage the cord and cause a fire. Do not remove
container labels or reuse empty containers to store different substances; laws mandate that the
labels of all substances specify an antidote.
B) Always pull a plug at the plug-in from the wall outlet. Pulling a plug by its cord can damage
the cord and plug unit, creating a dangerous situation. Not knowing which plants are poisonous
and which are not may pose a serious problem for children in the home. Always avoid
overloading outlets at any time because it may damage the cord and cause a fire. Do not remove
container labels or reuse empty containers to store different substances; laws mandate that the
labels of all substances specify an antidote.
C) Always pull a plug at the plug-in from the wall outlet. Pulling a plug by its cord can damage
the cord and plug unit, creating a dangerous situation. Not knowing which plants are poisonous
and which are not may pose a serious problem for children in the home. Always avoid
overloading outlets at any time because it may damage the cord and cause a fire. Do not remove
container labels or reuse empty containers to store different substances; laws mandate that the
labels of all substances specify an antidote.
D) Always pull a plug at the plug-in from the wall outlet. Pulling a plug by its cord can damage
the cord and plug unit, creating a dangerous situation. Not knowing which plants are poisonous
and which are not may pose a serious problem for children in the home. Always avoid
overloading outlets at any time because it may damage the cord and cause a fire. Do not remove
container labels or reuse empty containers to store different substances; laws mandate that the
labels of all substances specify an antidote.
Page Ref: 2708
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Nursing Process: Planning
Learning Outcome: 3. Describe specific nursing interventions aimed at reducing the risk of
injury or illness.

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Copyright © 2015 Pearson Education, Inc.
6) The nurse is caring for a client who will be discharged on a new blood pressure medication.
The medication the client is going home on increases the risk of orthostatic hypotension. What
should the nurse teach the client to prevent a fall injury at home?
A) Encourage appropriate lighting.
B) Provide a bedside commode.
C) Rise slowly when getting up.
D) Monitor activity tolerance.
Answer: C
Explanation:
A) Orthostatic hypotension can cause dizziness upon rising that can lead to falls. The nurse
instructs the client to rise slowly and stand in place for a few seconds until balance is assured.
Providing a bedside commode would be appropriate for the client with urinary urgency. Clients
with respiratory difficulties or heart ailments would want to monitor their activity tolerance
levels. Appropriate lighting would help the client experiencing impaired vision.
B) Orthostatic hypotension can cause dizziness upon rising that can lead to falls. The nurse
instructs the client to rise slowly and stand in place for a few seconds until balance is assured.
Providing a bedside commode would be appropriate for the client with urinary urgency. Clients
with respiratory difficulties or heart ailments would want to monitor their activity tolerance
levels. Appropriate lighting would help the client experiencing impaired vision.
C) Orthostatic hypotension can cause dizziness upon rising that can lead to falls. The nurse
instructs the client to rise slowly and stand in place for a few seconds until balance is assured.
Providing a bedside commode would be appropriate for the client with urinary urgency. Clients
with respiratory difficulties or heart ailments would want to monitor their activity tolerance
levels. Appropriate lighting would help the client experiencing impaired vision.
D) Orthostatic hypotension can cause dizziness upon rising that can lead to falls. The nurse
instructs the client to rise slowly and stand in place for a few seconds until balance is assured.
Providing a bedside commode would be appropriate for the client with urinary urgency. Clients
with respiratory difficulties or heart ailments would want to monitor their activity tolerance
levels. Appropriate lighting would help the client experiencing impaired vision.
Page Ref: 2714
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 4. Demonstrate client teaching aimed at reducing the risk of injury or
illness.

15
Copyright © 2015 Pearson Education, Inc.
7) The home health nurse is visiting a family and talking with the parent outside the bathroom
door while the toddlers are playing in the tub. Which client statement indicates that additional
teaching is required?
A) "Why don't we talk in the living room?"
B) "Let me get the children out of the tub so we can talk."
C) "I do not like to leave the children alone in the bathroom."
D) "I often bathe the children together."
Answer: A
Explanation:
A) Toddlers are at risk for drowning, even in small amounts of water. The nurse would want to
teach the parent that it is never appropriate to leave the toddlers unsupervised in the tub. Taking
the children out of the tub and a parent that does not want to leave toddlers alone in the bathroom
demonstrates an awareness of risk. There is no risk with bathing the children together.
B) Toddlers are at risk for drowning, even in small amounts of water. The nurse would want to
teach the parent that it is never appropriate to leave the toddlers unsupervised in the tub. Taking
the children out of the tub and a parent that does not want to leave toddlers alone in the bathroom
demonstrate an awareness of risk. There is no risk with bathing the children together.
C) Toddlers are at risk for drowning, even in small amounts of water. The nurse would want to
teach the parent that it is never appropriate to leave the toddlers unsupervised in the tub. Taking
the children out of the tub and a parent that does not want to leave toddlers alone in the bathroom
demonstrate an awareness of risk. There is no risk with bathing the children together.
D) Toddlers are at risk for drowning, even in small amounts of water. The nurse would want to
teach the parent that it is never appropriate to leave the toddlers unsupervised in the tub. Taking
the children out of the tub and a parent that does not want to leave toddlers alone in the bathroom
demonstrate an awareness of risk. There is no risk with bathing the children together.
Page Ref: 2711
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Nursing Process: Evaluation
Learning Outcome: 5. Summarize specific risks associated with different stages of the life span
and developmentally appropriate teaching to reduce these risks.

16
Copyright © 2015 Pearson Education, Inc.
8) A clinic nurse is preparing a class for new parents on the effects of poor prenatal nutrition.
The clinic nurse is aware that which is not an effect of poor prenatal nutrition?
A) Low birth weight
B) High birth weight
C) Premature birth
D) Altered brain function
Answer: B
Explanation:
A) During the prenatal period, poor nutrition can have the following effects: altered brain
function in the fetus, low birth weight, premature birth, jaundice, and a risk for learning
disorders. High birth weight is not associated with poor prenatal nutrition.
B) During the prenatal period, poor nutrition can have the following effects: altered brain
function in the fetus, low birth weight, premature birth, jaundice, and a risk for learning
disorders. High birth weight is not associated with poor prenatal nutrition.
C) During the prenatal period, poor nutrition can have the following effects: altered brain
function in the fetus, low birth weight, premature birth, jaundice, and a risk for learning
disorders. High birth weight is not associated with poor prenatal nutrition.
D) During the prenatal period, poor nutrition can have the following effects: altered brain
function in the fetus, low birth weight, premature birth, jaundice, and a risk for learning
disorders. High birth weight is not associated with poor prenatal nutrition.
Page Ref: 2709
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Teaching and Learning
Learning Outcome: 4. Demonstrate client teaching aimed at reducing the risk of injury or
illness.

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Copyright © 2015 Pearson Education, Inc.
9) The nursing instructor is educating a group of nursing students on sports-related injuries.
Which comment made by a student nurse would indicate to the nursing instructor the need for
further instruction?
A) "Clients who participate in sports, strenuous exercise, or athletics of any kind should be
educated about the dangers of unreported head injuries."
B) "Adolescents are at the greatest risk for not reporting sports-related injuries."
C) "Young adults are at the greatest risk for not reporting sports-related injuries."
D) "Clients who have been injured playing a sport need to be counseled on the risks of
unreported concussions."
Answer: C
Explanation:
A) Clients who participate in sports, strenuous exercise, or athletics of any kind should be
educated about the dangers of unreported head injuries. Adolescents are at the greatest risk for
not reporting sports-related injuries, but adults should be educated about the dangers as well.
Clients who have been injured playing a sport, or even those receiving a sports physical, could be
counseled by nurses about the risks of unreported concussions.
B) Clients who participate in sports, strenuous exercise, or athletics of any kind should be
educated about the dangers of unreported head injuries. Adolescents are at the greatest risk for
not reporting sports-related injuries, but adults should be educated about the dangers as well.
Clients who have been injured playing a sport, or even those receiving a sports physical, could be
counseled by nurses about the risks of unreported concussions.
C) Clients who participate in sports, strenuous exercise, or athletics of any kind should be
educated about the dangers of unreported head injuries. Adolescents are at the greatest risk for
not reporting sports-related injuries, but adults should be educated about the dangers as well.
Clients who have been injured playing a sport, or even those receiving a sports physical, could be
counseled by nurses about the risks of unreported concussions.
D) Clients who participate in sports, strenuous exercise, or athletics of any kind should be
educated about the dangers of unreported head injuries. Adolescents are at the greatest risk for
not reporting sports-related injuries, but adults should be educated about the dangers as well.
Clients who have been injured playing a sport, or even those receiving a sports physical, could be
counseled by nurses about the risks of unreported concussions.
Page Ref: 2712
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Teaching and Learning
Learning Outcome: 5. Summarize specific risks associated with different stages of the life span
and developmentally appropriate teaching to reduce these risks.

18
Copyright © 2015 Pearson Education, Inc.
Exemplar 51.2 Workplace Safety

1) A nurse educator is teaching nursing students about the application of personal protective
equipment (PPE) and emphasizes the importance of appropriate technique when removing the
face mask. Which student response indicates appropriate understanding?
A) "I will touch the mask by the strings only."
B) "I will bend the strip at the top of the mask."
C) "I will tie the strings in a bow."
D) "I will loop the ties over the ears."
Answer: A
Explanation:
A) Touching the mask by the strings for both putting it on and taking it off is the appropriate
intervention because the mask is considered contaminated. Bending the strip at the top of the
mask, looping the ties over the ears, and tying the strings in a bow under the chin are all
interventions used when applying a mask.
B) Touching the mask by the strings for both putting it on and taking it off is the appropriate
intervention because the mask is considered contaminated. Bending the strip at the top of the
mask, looping the ties over the ears, and tying the strings in a bow under the chin are all
interventions used when applying a mask.
C) Touching the mask by the strings for both putting it on and taking it off is the appropriate
intervention because the mask is considered contaminated. Bending the strip at the top of the
mask, looping the ties over the ears, and tying the strings in a bow under the chin are all
interventions used when applying a mask.
D) Touching the mask by the strings for both putting it on and taking it off is the appropriate
intervention because the mask is considered contaminated. Bending the strip at the top of the
mask, looping the ties over the ears, and tying the strings in a bow under the chin are all
interventions used when applying a mask.
Page Ref: 2715
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Nursing Process: Evaluation
Learning Outcome: 2. Provide strategies and client teaching appropriate to reducing risk for
injury or illness in the healthcare setting.

19
Copyright © 2015 Pearson Education, Inc.
2) The nurse is preparing discharge instructions for a client with an open surgical wound. Which
instructions are important for the nurse to include for this client?
Select all that apply.
A) Apply lubricating lotion to the edges of the wound.
B) Notify your physician if you notice edema, heat, or tenderness at the wound site.
C) Thoroughly irrigate the wound with hydrogen peroxide.
D) Wash hands before and after changing the surgical dressing.
E) Adjust your diet to increase the amount of protein.
Answer: B, D, E
Explanation:
A) A client being discharged with an open surgical wound has to be instructed on the detection
of infection because the skin is the first line of defense. Signs such as edema, heat, and
tenderness would indicate a local infection. Increasing protein in the diet will help to enhance
wound healing. Hand hygiene before and after dressing changes is essential to decrease the risk
of a wound infection. Applying lubricating lotion to the edges of a wound would impede the
healing process. Irrigating with hydrogen peroxide would break down good granulating tissue, so
this also would not increase healing.
B) A client being discharged with an open surgical wound has to be instructed on the detection
of infection because the skin is the first line of defense. Signs such as edema, heat, and
tenderness would indicate a local infection. Increasing protein in the diet will help to enhance
wound healing. Hand hygiene before and after dressing changes is essential to decrease the risk
of a wound infection. Applying lubricating lotion to the edges of a wound would impede the
healing process. Irrigating with hydrogen peroxide would break down good granulating tissue, so
this also would not increase healing.
C) A client being discharged with an open surgical wound has to be instructed on the detection
of infection because the skin is the first line of defense. Signs such as edema, heat, and
tenderness would indicate a local infection. Increasing protein in the diet will help to enhance
wound healing. Hand hygiene before and after dressing changes is essential to decrease the risk
of a wound infection. Applying lubricating lotion to the edges of a wound would impede the
healing process. Irrigating with hydrogen peroxide would break down good granulating tissue, so
this also would not increase healing.
D) A client being discharged with an open surgical wound has to be instructed on the detection
of infection because the skin is the first line of defense. Signs such as edema, heat, and
tenderness would indicate a local infection. Increasing protein in the diet will help to enhance
wound healing. Hand hygiene before and after dressing changes is essential to decrease the risk
of a wound infection. Applying lubricating lotion to the edges of a wound would impede the
healing process. Irrigating with hydrogen peroxide would break down good granulating tissue, so
this also would not increase healing.

20
Copyright © 2015 Pearson Education, Inc.
E) A client being discharged with an open surgical wound has to be instructed on the detection of
infection because the skin is the first line of defense. Signs such as edema, heat, and tenderness
would indicate a local infection. Increasing protein in the diet will help to enhance wound
healing. Hand hygiene before and after dressing changes is essential to decrease the risk of a
wound infection. Applying lubricating lotion to the edges of a wound would impede the healing
process. Irrigating with hydrogen peroxide would break down good granulating tissue, so this
also would not increase healing.
Page Ref: 2698
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 2. Provide strategies and client teaching appropriate to reducing risk for
injury or illness in the healthcare setting.

21
Copyright © 2015 Pearson Education, Inc.
3) The unit nurse educator is planning to instruct the staff on interventions to reduce the risk of
infection for the client population. Which intervention is the most important to decrease client
infection?
A) Practice appropriate hand hygiene.
B) Assess vital signs only once daily.
C) Raise the temperature in the client's room.
D) Wear a mask for all client care.
Answer: A
Explanation:
A) Hand hygiene is always the first and best way to stop the spread of microorganisms, which
cause infections. Assessing vital signs is important but should be done more frequently than once
daily. Raising the temperature in a client's room would contribute to the growth of
microorganisms. Wearing a mask for all clients is not practical and is unnecessary unless a
microorganism is airborne and the client is in isolation.
B) Hand hygiene is always the first and best way to stop the spread of microorganisms, which
cause infections. Assessing vital signs is important but should be done more frequently than once
daily. Raising the temperature in a client's room would contribute to the growth of
microorganisms. Wearing a mask for all clients is not practical and is unnecessary unless a
microorganism is airborne and the client is in isolation.
C) Hand hygiene is always the first and best way to stop the spread of microorganisms, which
cause infections. Assessing vital signs is important but should be done more frequently than once
daily. Raising the temperature in a client's room would contribute to the growth of
microorganisms. Wearing a mask for all clients is not practical and is unnecessary unless a
microorganism is airborne and the client is in isolation.
D) Hand hygiene is always the first and best way to stop the spread of microorganisms, which
cause infections. Assessing vital signs is important but should be done more frequently than once
daily. Raising the temperature in a client's room would contribute to the growth of
microorganisms. Wearing a mask for all clients is not practical and is unnecessary unless a
microorganism is airborne and the client is in isolation.
Page Ref: 2717
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 1. Provide strategies and client teaching appropriate to reducing risk for
injury or illness in the workplace.

22
Copyright © 2015 Pearson Education, Inc.
4) A student nurse is reviewing client education about infection control measures. Which nursing
measure is appropriate when teaching the client about breaking a link in the chain of infection?
A) Use personal protective equipment (PPE) sparingly.
B) Place contaminated linens in a paper bag.
C) Wear gloves at all times.
D) Cover the mouth and nose when sneezing.
Answer: D
Explanation:
A) The most appropriate area of client education is to cover the mouth and nose when sneezing
to prevent airborne droplets from escaping into the air for others to contract in the chain of
infection. Placing linens in a paper bag would allow germs to come out through the bag, and the
linen would act as a fomite, thus allowing the chain to continue. PPE is not necessary in the
community setting. Gloves are not necessary for clients to wear in the home or community.
B) The most appropriate area of client education is to cover the mouth and nose when sneezing
to prevent airborne droplets from escaping into the air for others to contract in the chain of
infection. Placing linens in a paper bag would allow germs to come out through the bag, and the
linen would act as a fomite, thus allowing the chain to continue. PPE is not necessary in the
community setting. Gloves are not necessary for clients to wear in the home or community.
C) The most appropriate area of client education is to cover the mouth and nose when sneezing
to prevent airborne droplets from escaping into the air for others to contract in the chain of
infection. Placing linens in a paper bag would allow germs to come out through the bag, and the
linen would act as a fomite, thus allowing the chain to continue. PPE is not necessary in the
community setting. Gloves are not necessary for clients to wear in the home or community.
D) The most appropriate area of client education is to cover the mouth and nose when sneezing
to prevent airborne droplets from escaping into the air for others to contract in the chain of
infection. Placing linens in a paper bag would allow germs to come out through the bag, and the
linen would act as a fomite, thus allowing the chain to continue. PPE is not necessary in the
community setting. Gloves are not necessary for clients to wear in the home or community.
Page Ref: 2717
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 2. Provide strategies and client teaching appropriate to reducing risk for
injury or illness in the healthcare setting.

23
Copyright © 2015 Pearson Education, Inc.
5) While reviewing safety precautions with the staff in a long-term care facility, which step
should the nurse emphasize that helps to promote a safe environment for the clients?
A) Keep clutter out of the hallway and inside the client's room.
B) Provide dim lighting.
C) Turn off alarms to reduce noise.
D) Have the client wear rubber skid-resistant slippers.
Answer: D
Explanation:
A) Having the client wear rubber skid-resistant slippers is the most appropriate intervention to
decrease the risk of client falls, which will promote a safe environment. Dim lighting will
increase the risk of client falls. The environment should be clutter-free, because any clutter can
cause the client to fall. Noise should be kept to a minimum, but turning off alarms would
endanger a client.
B) Having the client wear rubber skid-resistant slippers is the most appropriate intervention to
decrease the risk of client falls, which will promote a safe environment. Dim lighting will
increase the risk of client falls. The environment should be clutter-free, because any clutter can
cause the client to fall. Noise should be kept to a minimum, but turning off alarms would
endanger a client.
C) Having the client wear rubber skid-resistant slippers is the most appropriate intervention to
decrease the risk of client falls, which will promote a safe environment. Dim lighting will
increase the risk of client falls. The environment should be clutter-free, because any clutter can
cause the client to fall. Noise should be kept to a minimum, but turning off alarms would
endanger a client.
D) Having the client wear rubber skid-resistant slippers is the most appropriate intervention to
decrease the risk of client falls, which will promote a safe environment. Dim lighting will
increase the risk of client falls. The environment should be clutter-free, because any clutter can
cause the client to fall. Noise should be kept to a minimum, but turning off alarms would
endanger a client.
Page Ref: 2703
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Planning
Learning Outcome: 3. Recommend strategies for promoting safety in the healthcare setting.

24
Copyright © 2015 Pearson Education, Inc.
6) The nurse is planning care for a client who is experiencing confusion. What should the nurse
do to ensure safety for this client?
A) Keep the windows in the client's room closed.
B) Keep the side rails up on the bed when the client is with a staff member.
C) Place the call bell next to the client.
D) Administer ordered medication.
Answer: C
Explanation:
A) To prevent falls in the confused client, the nurse should place the call bell next to the client so
that the client does not fall trying to reach for it. The bed rails do not need to be up when the
client is with a staff member but should be up if the client is alone. Most agency windows are
kept closed or are the type that cannot open wide enough to cause injury. Administering ordered
medication will not prevent injury to the client.
B) To prevent falls in the confused client, the nurse should place the call bell next to the client so
that the client does not fall trying to reach for it. The bed rails do not need to be up when the
client is with a staff member but should be up if the client is alone. Most agency windows are
kept closed or are the type that cannot open wide enough to cause injury. Administering ordered
medication will not prevent injury to the client.
C) To prevent falls in the confused client, the nurse should place the call bell next to the client so
that the client does not fall trying to reach for it. The bed rails do not need to be up when the
client is with a staff member but should be up if the client is alone. Most agency windows are
kept closed or are the type that cannot open wide enough to cause injury. Administering ordered
medication will not prevent injury to the client.
D) To prevent falls in the confused client, the nurse should place the call bell next to the client so
that the client does not fall trying to reach for it. The bed rails do not need to be up when the
client is with a staff member but should be up if the client is alone. Most agency windows are
kept closed or are the type that cannot open wide enough to cause injury. Administering ordered
medication will not prevent injury to the client.
Page Ref: 2715
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Planning
Learning Outcome: 3. Recommend strategies for promoting safety in the healthcare setting.

25
Copyright © 2015 Pearson Education, Inc.
7) A new graduate has accepted a position as a medical-surgical nurse at a local university
hospital. In order to provide safe care to clients, the nurse should plan to develop which
competency?
A) Creating a culture of trust within the hospital
B) Functioning as a member of the healthcare team
C) Promoting appropriate values that clients should adopt
D) Reporting families for bringing food to the client's room
Answer: B
Explanation:
A) New nurses should learn about the healthcare team members and determine whom to
collaborate with in certain situations. Rather than reporting families, the nurse would work with
families to help meet their needs if food is not allowed in the room. The nurse would respect the
values of clients and not seek to impose any on the clients. Creating a culture of trust is a system
change that is implemented by the administration.
B) New nurses should learn about the healthcare team members and determine whom to
collaborate with in certain situations. Rather than reporting families, the nurse would work with
families to help meet their needs if food is not allowed in the room. The nurse would respect the
values of clients and not seek to impose any on the clients. Creating a culture of trust is a system
change that is implemented by the administration.
C) New nurses should learn about the healthcare team members and determine whom to
collaborate with in certain situations. Rather than reporting families, the nurse would work with
families to help meet their needs if food is not allowed in the room. The nurse would respect the
values of clients and not seek to impose any on the clients. Creating a culture of trust is a system
change that is implemented by the administration.
D) New nurses should learn about the healthcare team members and determine whom to
collaborate with in certain situations. Rather than reporting families, the nurse would work with
families to help meet their needs if food is not allowed in the room. The nurse would respect the
values of clients and not seek to impose any on the clients. Creating a culture of trust is a system
change that is implemented by the administration.
Page Ref: 2616
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 4. Identify nursing competencies important to promoting client safety and
quality of care.

26
Copyright © 2015 Pearson Education, Inc.
8) The nurse is preparing to assess the client's blood pressure using an electronic monitoring unit
and notices that the end of the cord is frayed. To prevent harm, what should the nurse do?
A) Plug the machine in to make sure it works appropriately.
B) Get another machine from the equipment room.
C) Label the machine as broken and notify engineering.
D) Complete an incident report.
Answer: C
Explanation:
A) The best action to prevent injury is to label the machine with information about the frayed
cord and notify engineering or the department responsible for equipment safety. The nurse would
obtain another machine, but placing the machine with the frayed wire in the equipment room
puts another client at risk. The nurse could be jeopardizing personal safety by plugging the
machine in. Because no injury has occurred, it would not be appropriate to complete an incident
report.
B) The best action to prevent injury is to label the machine with information about the frayed
cord and notify engineering or the department responsible for equipment safety. The nurse would
obtain another machine, but placing the machine with the frayed wire in the equipment room
puts another client at risk. The nurse could be jeopardizing personal safety by plugging the
machine in. Because no injury has occurred, it would not be appropriate to complete an incident
report.
C) The best action to prevent injury is to label the machine with information about the frayed
cord and notify engineering or the department responsible for equipment safety. The nurse would
obtain another machine, but placing the machine with the frayed wire in the equipment room
puts another client at risk. The nurse could be jeopardizing personal safety by plugging the
machine in. Because no injury has occurred, it would not be appropriate to complete an incident
report.
D) The best action to prevent injury is to label the machine with information about the frayed
cord and notify engineering or the department responsible for equipment safety. The nurse would
obtain another machine, but placing the machine with the frayed wire in the equipment room
puts another client at risk. The nurse could be jeopardizing personal safety by plugging the
machine in. Because no injury has occurred, it would not be appropriate to complete an incident
report.
Page Ref: 2715
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 5. Recommend strategies for reducing procedure- and equipment-related
accidents.

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Copyright © 2015 Pearson Education, Inc.
9) A nurse preceptor on the progressive care unit is orienting a newly licensed nurse. Which
action taken by the newly licensed nurse should require immediate intervention by the nurse
preceptor?
A) The nurse preceptor observes the newly licensed nurse recapping a needle using the scoop
method.
B) The nurse preceptor observes the newly licensed nurse recapping the needle with the use of
forceps.
C) The nurse preceptor observes the newly licensed nurse picking up contaminated broken glass.
D) The nurse preceptor observes the newly licensed nurse disposing of a needle in the sharps
container.
Answer: C
Explanation:
A) When working with used or contaminated sharps, nurses will employ extra precautions so as
to avoid unnecessary injuries. Needles that have been used will be disposed of in an appropriate
sharps container. If sharps do need to be recapped this should be done with the use of another
device (such as forceps or tongs), or with the scoop method. Nurses should never hold the cap in
one hand while trying to guide the tip of the needle into the cap with the other—this method
substantially increases the risk of a sharp-related injury. According to OSHA, if contaminated
glass is broken it should never be picked up by hand; a broom and dustpan or forceps should be
used instead. Therefore if the nurse preceptor observes the newly licensed nurse picking up the
contaminated broken glass she needs to immediately intervene.
B) When working with used or contaminated sharps, nurses will employ extra precautions so as
to avoid unnecessary injuries. Needles that have been used will be disposed of in an appropriate
sharps container. If sharps do need to be recapped this should be done with the use of another
device (such as forceps or tongs), or with the scoop method. Nurses should never hold the cap in
one hand while trying to guide the tip of the needle into the cap with the other—this method
substantially increases the risk of a sharp-related injury. According to OSHA, if contaminated
glass is broken it should never be picked up by hand; a broom and dustpan or forceps should be
used instead. Therefore if the nurse preceptor observes the newly licensed nurse picking up the
contaminated broken glass she needs to immediately intervene.
C) When working with used or contaminated sharps, nurses will employ extra precautions so as
to avoid unnecessary injuries. Needles that have been used will be disposed of in an appropriate
sharps container. If sharps do need to be recapped this should be done with the use of another
device (such as forceps or tongs), or with the scoop method. Nurses should never hold the cap in
one hand while trying to guide the tip of the needle into the cap with the other—this method
substantially increases the risk of a sharp-related injury. According to OSHA, if contaminated
glass is broken it should never be picked up by hand; a broom and dustpan or forceps should be
used instead. Therefore if the nurse preceptor observes the newly licensed nurse picking up the
contaminated broken glass she needs to immediately intervene.

28
Copyright © 2015 Pearson Education, Inc.
D) When working with used or contaminated sharps, nurses will employ extra precautions so as
to avoid unnecessary injuries. Needles that have been used will be disposed of in an appropriate
sharps container. If sharps do need to be recapped this should be done with the use of another
device (such as forceps or tongs), or with the scoop method. Nurses should never hold the cap in
one hand while trying to guide the tip of the needle into the cap with the other—this method
substantially increases the risk of a sharp-related injury. According to OSHA, if contaminated
glass is broken it should never be picked up by hand; a broom and dustpan or forceps should be
used instead. Therefore if the nurse preceptor observes the newly licensed nurse picking up the
contaminated broken glass she needs to immediately intervene.
Page Ref: 2716
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
Nursing Process: Teaching and Learning
Learning Outcome: 3. Recommend strategies for promoting safety in the healthcare setting.

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