TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 04: Patient Safety and Quality Improvement Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is caring for an older patient who has a non–weight-bearing cast on the left lower
extremity. The patient ambulates without using a walker despite repeated instruction from the nurse to call for assistance. Which response by the nurse is most likely to keep the patient from falling? a. Apply a vest restraint and offer frequent toileting. b. Plan fall prevention with patient, family, and health care provider. c. Inform family that the patient needs physical restraints. d. Document that the patient has a high potential for falling. ANS: B
Planning an individualized fall prevention program with the help of the patient, family, and health care provider is more likely to reduce the patient’s risk of falls because the patient gains some control over the plan of care and still benefits from the input of the provider, family, and nurse. A combination of interventions is more useful in preventing falls. Including the patient in planning also gives him or her ownership of the plan, making it less likely the patient will disregard this plan. Restraints are associated with serious injuries and are not recommended for use unless nothing else has worked. Alternative methods of engaging the patient in a care plan that minimizes risks should be exhausted before resorting to restraints. Documenting the patient’s risk is important because it communicates the information and records the nurse’s acknowledgment of the risk, but it is not as effective as engaging the patient in planning care as a prevention technique because N it is indirect. DIF: Cognitive Level: Applying TOP: Nursing Process: Planning
OBJ: NCLEX: Safe and Effective Care Environment
2. The nurse plans a fall prevention program for a confused patient. Which task from the
program is suitable for the nurse to delegate to nursing assistive personnel (NAP)? a. Evaluating patient understanding of fall prevention plan b. Keeping the patient’s bed in the low position at all times c. Assessing the patient’s circulatory and respiratory status d. Instructing the patient’s family about alternatives to restraints ANS: B
The nurse may delegate keeping the bed lowered to the NAP because the NAP is trained to perform the task with proper nursing supervision. Skills used to prevent falls can often be delegated. The nurse does not delegate the remaining options because they involve aspects of the nursing process that require the advanced training of a nurse to perform. DIF: Cognitive Level: Applying TOP: Nursing Process: Planning
OBJ: NCLEX: Safe and Effective Care Environment
3. The nurse plans care for a patient who requires physical restraint. Which is a suitable goal for
this patient? a. The patient remains free of any injury. b. The nurse checks the restraint every hour.
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