Chapter 32: Home Care Safety

Multiple Choice

1. The nurse is working with a client on the plan of care. Which client behavior does the nurse recognize as most illustrative that the client will cooperate with a plan of care?

a. Willingness to attempt a return demonstration b. Refusal to talk about the needed assistive device c. States that a few days of rest are all that is needed for recovery d. States the equipment is too complex to learn

ANS: A

The client who is willing to perform a return demonstration for the nurse is demonstrating a health-seeking behavior; thus the nurse plans interventions to facilitate client motivation and drive to master the task. The client who refuses to talk about the equipment is angry or in denial. The client who states that resting will solve the problem is in denial. The client who states the task is too difficult has a poor self-image and can benefit from slow, steady teaching and encouragement.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. The client’s oxygen saturation ranges from 88% to 90%. b. Client is 2 days postoperative after emergency amputation. c. The family lacks financial resources for supplies and equipment. d. The family agrees to the therapeutic diet and exercise plan.

2. The nurse plans discharge teaching for several clients. Which client and family are most likely to benefit from the nurse’s teaching plan?

ANS: D

The family that agrees to the therapeutic diet and exercise plan is most likely to benefit from the nurse’s teaching plan because the members are enthusiastic and positive, providing motivation and energy to succeed. They are willing to change their behavior when change is required. The hypoxic client will most likely have difficulty following directions and retaining information while struggling for oxygen. The client who had an emergency amputation is not ready for discharge because it is unlikely that the client received enough physical therapy; in addition, the client most likely had significant blood loss and could still be unstable. The client and family lacking financial resources for home health care need community resources before the teaching plan can be implemented.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. Stores a flashlight next to the bed. b. Checks batteries in the smoke detector. c. Stores the area rugs in the basement. d. Leaves a loaded gun in the nightstand.

3. The nurse finishes discharge teaching for the client after a home assessment. Which action by the client requires follow-up information from the home care nurse?

ANS: D

The nurse needs to teach the client to keep the gun unloaded in a locked area and the bullets in a separate area for safety. Storing a flashlight, checking smoke detector batteries, and removing area rugs are suitable safety measures.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Conduct a home assessment focusing on fall prevention. b. Explain community services for older clients. c. Help the client check the fit of his shoes. d. Tell the family he can do whatever she wants.

4. A client’s family insists that the client live with one of the family members permanently because of a shuffling gait, but the client refuses. Which approach is most effective to provide a safe environment while also acting as a client advocate?

ANS: A

The shuffling gait is a safety hazard and could cause the client to fall. The nurse first conducts a safety assessment of the house to determine factors promoting safety and factors that do not promote safety. It is possible that some modifications (i.e., wall railings) would be sufficient to keep the client safe at home. Checking shoes for fit is important as shoes that are too big or don’t fit totally on the foot can be a tripping hazard, but this is not as important as a comprehensive home safety assessment. Explaining the community services available will not provide safety for this client. Telling the family that he or she can do whatever he or she wants ignores the client’s specific safety needs, the families concerns, and effectively removes them from the discussion.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Older clients lack the motivation to learn. b. Older clients can learn if one speaks loudly. c. Visual aids are not helpful for older adults. d. The ability to learn remains intact despite aging.

5. The client’s son tells the nurse that his parent is unable to learn about new medications because of her advanced age. Which does the nurse include in family teaching?

ANS: D

The nurse instructs the family that older clients are willing and able to learn new things, including how to self-administer new medication. In fact, nursing research indicates that learning new things is a stimulant for improved cognitive function. Learning can take more time for older clients, but they are capable nonetheless, unless they have a cognitive disorder that would prevent learning, such as dementia. Lack of motivation is a generalization. Many older clients have a hearing impairment; thus, the nurse speaks clearly and directly in front of the client to facilitate hearing. Visual aids are as helpful for older adults as they are for any age-group. Using visual aids is more dependent on the client’s learning style than on age.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Trains the client to avoid rubbing the injection site. b. Instructs the client to store used needles in a hard plastic bottle with a tight lid. c. Shows the client how to draw up precise insulin doses. d. Ensures that the client has low-dose syringes for small doses.

6. The nurse instructs the client to perform self-injections of insulin. Which does the nurse include in client teaching to prevent a home accident to other family members?

ANS: B

The nurse instructs the client to dispose of used needles in a hard plastic bottle with a tight lid (or a medically approved sharps container if one is available) to prevent accidental needlestick injuries to other family members; if small children are in the home, the nurse suggests keeping the bottle in a locked cabinet. The nurse instructs the client to protect his or her skin integrity by not rubbing the injection site. The nurse shows the client how to draw up precise doses of insulin and ensures that the client uses the best equipment to avoid hyperglycemic or hypoglycemic emergencies. However, problems in these areas should not cause accidents involving other family members.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Install a grab bar near the shower or tub. b. Take medications at bedtime to avoid side effects. c. Install additional towel bars near the shower or tub. d. Wear socks during the day for foot health.

7. The nurse prepares to discharge an older client who has fallen in the hospital to home. Which safety measure does the nurse include in client and family teaching?

ANS: A

A grab bar is rigid and can provide effective support in case of a near fall. Medications may need to be spaced during the day, or may include diuretics that cause nocturia, possibly leading to a fall at night. Other medications may also increase the risk for falling if taken at night. Towel bars are ineffective safety bars; the nurse instructs the client to install safety bars in the bathroom. A fall-prone client should wear a well-fitting pair of shoes during the day because socks are slippery.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Tell the client to get out of the car slowly. b. Move the client’s seat at least 10 inches from the air bag. c. Instruct the driver to let the client off at the door. d. Instruct the client to avoid rib and chest injury by not using the seatbelt.

8. A frail older client is being driven to the grocery store. Which aspect of safety prevention is most important for the nurse to stress to this client?

ANS: B

Frail older adults should not ride in the passenger seat of the car with airbags unless the seat can be at least 10 inches from the airbag. The impact of the airbag, if deployed, can cause serious injury because of the client’s frailty. There are no data supporting the client’s orthostatic hypotension. He or she should change positions slowly anytime, not only when riding in a car. Letting the client off at the door is a poor suggestion as the frail person may need help and may not be able to stand there waiting for the driver to return. Anyone in a car needs to wear a seat belt.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Turn on a light before he or she walks into a dark room. b. Clean the top of the stove and appliances at least twice a week. c. Post emergency numbers on the front of the refrigerator. d. Use fluorescent lighting to decrease glare.

9. The nurse is helping a client with diminished sight to remain as independent in the home as possible. Which does the nurse include as a priority in client teaching to improve home safety for the client?

ANS: A

The nurse instructs the client with diminished sight to light living areas. This decreases the chance of bumping into things and becoming injured. The top of the stove and the other appliances should be clean and grease-free, but the cleaning schedule will depend on the cooking schedule; more or less cleaning may be needed. The nurse instructs the client to post emergency numbers with large print to increase his or her ability to see them. The numbers should also be posted by the phone or in an easily accessible place. The front of the refrigerator may or may not be the ideal place. Fluorescent lighting should not be used as it causes worse glare.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. The client demonstrates proper disposal of medications in the toilet. b. The client stores the medication bottles on the bathroom counter. c. The client can read each medication label and explain when to take each one. d. The client explains ways to decrease the number of times he or she takes the medications.

10. The nurse prepares to teach the client about managing multiple medications at home. Which client outcome does the nurse hope to accomplish as a result of client teaching?

ANS: C

The nurse’s goal is to ensure that the client is able to identify and understand each prescription ordered and when to take it. Although the FDA does not recommend routine flushing of discarded medications down the toilets, some medications with high abuse potential should be flushed. Medications should be stored in a dark, locked, dry place, not on an open counter exposed to water. The nurse instructs the client to avoid mixing several medications in the same container because this can cause confusion.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Take the diuretic in the morning at 8 AM and the antihypertensive pill at 1 PM. b. Take both medications at the same time so the client can remember. c. Change positions slowly, especially from lying down to standing. d. Take the medications with orange juice to maintain the potassium level.

11. The nurse is teaching the client how to safely take a diuretic and an antihypertensive pill. Which information does the nurse write for the client to reduce client risk of falls while maintaining the therapeutic medication regimen?

ANS: A

The nurse instructs the client to take a diuretic early in the day so trips to the bathroom will not interrupt sleep at night. Taking the medications at different times minimizes the side effects (e.g., lowering the blood pressure too fast and causing dizziness, which can lead to falls). The two types of medications taken together could cause a major drop in blood pressure and cause the client to fall. The nurse instructs the older client to change positions slowly, but this doesn’t include instructions about scheduling the medications. There is no information to support whether or not the medications deplete potassium.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. The client paces and cannot be redirected easily. b. The client sleeps 6 hours at night and naps during the day. c. The client gets tired when cleaning the kitchen after cooking dinner. d. The client uses a space heater for supplemental heat.

12. The nurse is caring for an older client who has been getting more confused recently. What other characteristics might the family notice that alerts the nurse that the client may be at risk for wandering?

ANS: A

Pacing with difficulty being redirected is a characteristic that the family needs to report to the nurse. Six hours of sleep at night with a daytime nap is an expected sleep pattern for an older client. Tiring after cleaning the kitchen following cooking dinner is not unexpected for an older client. A space heater is not necessarily a hazard for a client with confusion as long as it is used appropriately. The space heater is also not related to wandering.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Remove the furniture because it is a safety hazard. b. Discuss the unsettling nature of change with the client. c. Instruct the client about potential injuries from falls. d. Explain the nursing responsibility to reduce the risk.

13. The nurse completes a home safety assessment and recommends removing a few pieces of large furniture to widen the pathway for a client who ambulates with a walker. However, the client refuses to allow furniture to be removed. Which action should the nurse take at this time?

ANS: B

The nurse invites the client to discuss change and its potential to cause distress (even when the change is desirable) to gather additional information about client refusal to remove a few pieces of furniture. The client can fear loss of control, grieve loss of function, or deny his physical limitations. The more the nurse knows about the client’s feelings and thoughts about the situation, the greater the potential for the nurse to facilitate client home safety. The nurse has no right to move the client’s furniture because the client retains the right to self-determination and to refuse therapy. The nurse should provide information about the client’s risk from falling; however, he or she should phrase the information carefully to avoid a threatening or condescending manner. The client’s safety is not about the nurse, and it is unethical for the nurse to use guilt to coerce the client.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. Install extra towel bars in the bathtub and near the toilet. b. Arrange the furniture so that pathways are wide enough and clear. c. Have a neighbor check on the client every afternoon. d. Secure throw rugs to the floor with double-sided tape.

14. The nurse teaches an older client about minimizing the risk of falls at home. Which does the nurse include in client teaching to prevent falls?

ANS: B

To prevent falls in the home, the nurse instructs the client to keep furniture arrangements so that the furniture can be walked around easily and keep walking paths free of clutter. If a change must occur, the client should practice moving around in the new arrangement with assistance as much as possible and use full lighting during any ambulation. Towel bars are not sturdy. Safety grab bars should be installed in the bathroom to help prevent falls. The neighbor can help to prevent a fall by assisting the client with awkward tasks but checking in once a day will not prevent a fall. Throw rugs and area rugs are trip hazards because they create an uneven surface, with or without tape.

N

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Collaborate for a psychiatric evaluation. b. Call a social worker to assess client needs. c. Ask family members for additional information. d. Review how the client takes care of things at home.

15. The nurse assesses a home care client who has a possible cognitive impairment. Which does the nurse implement to validate the assessment finding before planning suitable nursing care?

ANS: D

The nurse reviews home maintenance duties with the client before planning suitable nursing care or follow-up nursing interventions for a client who has a possible cognitive impairment. After completing the client interview, the nurse compares the client assessment findings to the appearance of the house to evaluate the consistency of client perceptions. This information provides valuable information about client self-care abilities. The nurse does not need a psychiatric evaluation or a social worker yet but can include the request in follow-up nursing care. The nurse completes the client evaluation first before obtaining additional information from the family.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. Large-print medication labels b. An easily opened medication organizer c. A telephone with a vibrating ringer d. A color-coded medication schedule

16. The home care nurse assists a client with impaired fine-motor skills. Which should the nurse implement to benefit the client?

ANS: B

The nurse facilitates client self-administration of medications by organizing the medication in easy-open containers for this client. Large-print labels and color-coded systems assist a client with a visual impairment. A telephone equipped with a vibrating ringer assists a client with a hearing impairment.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Provides client with a list of medication websites. b. Instructs client to decrease dose when feeling better. c. Discusses strategies for client use to prevent addiction. d. Develops a clear medication schedule with client help.

17. The nurse prepares the client to self-administer medications at home. Which does the nurse implement to increase the chance of client compliance with the therapeutic regimen?

ANS: D

Many clients take medication improperly and thereby increase the risks of adverse effects and ineffective therapy. One method to increase client compliance is to simplify medication administration with a schedule for client use. The nurse develops the schedule with the client’s assistance to engage the client in therapy and tailor the schedule to suit the client’s needs. Clients take medication improperly because many misunderstand the risk of noncompliance with therapy; thus, the nurse instructs the client about the risks and benefits of therapy and noncompliance to increase client ability to make an informed decision. The nurse instructs the client to take the medication as prescribed. Clients may fear addiction to medication, including medications that are not addictive, primarily from lack of education; the nurse explains that most medications are not addictive. In addition, the nurse explains the low rate of addiction to opioids for clients with real pain. The nurse educates the client on self-administration of other addicting agents and how to avoid addiction.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Praise the client for having the extinguisher. b. Have the client demonstrate/explain use of the extinguisher. c. Check to see if the extinguisher is still fully charges. d. Create a schedule for the client to change the extinguisher batteries.

18. The nurse is conducting a home safety assessment and notes the client has a fire extinguisher near the stove. What action by the nurse is most appropriate?

ANS: B

While the nurse does offer the client positive reinforcement for having a fire extinguisher and checks that it is ready for use, the extinguisher will be of no use unless the client can actually use it. The nurse asks the client to explain how to use the extinguisher, and might encourage a role play where the client demonstrates how he or she would use it. This also allows the nurse to ensure the client can manipulate it. The fire extinguisher does not have batteries.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. Consult the provider about a physical therapy referral. b. Arrange a full neurocognitive assessment for the client. c. Assess the client’s food and beverage preferences. d. Teach the client and family ways to prevent falls.

19. The nurse assesses a client using the Folstein test (Mini Mental Status Exam [MMSE]) and the client scores a 15. What action by the nurse is most appropriate?

ANS: B

The Folstein test, or Mini-Mental Status Exam, is a screening tool for cognitive impairment. If the client scores 21 or less, he or she needs further assessment. The nurse arranges for a comprehensive neurocognitive evaluation. The Folstein test is not used to assess physical functioning, nutrition, or fall risk.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation

Multiple Response

1. The Joint Commission has identified goals related to client safety in the home. These goals focus on which of the following? (Select all that apply.)

a. Patient identification b. Medication safety c. Fall prevention d. Patient education e. Safety risk identification

ANS: A, B, C, E

The Joint Commission has identified five goals that include:

1. Identifying patients correctly (following procedure to be sure patients receive the correct medications).

2. Using medicines safely (ensuring a patient has one up-to-date medication list and understands his or her medications)

3. Preventing infection (using hand hygiene)

4. Preventing clients from falling (recognizing fall risks and implementing preventive strategies)

5. Identifying client safety risks (specifically risks associated with oxygen therapy).

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Location of fall b. Time of fall c. Severity of fall d. Trauma after fall e. Place of fall f. Activity at time of fall

2. The nurse is assessing a client who has fallen at home using the mnemonic SPLATT. This refers to what assessment factors? (Select all that apply.)

ANS: A, B, D, F

SPLATT refers to:

Symptoms at time of fall

Previous fall

Location of fall

Activity at time of fall

Time of fall

Trauma after fall

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. Ask the client about his or her financial situation. b. Make changes that support the client’s independence. c. Only make the changes necessary to address disabilities. d. Let the client make the final decision whenever possible. e. Educate the family about preserving client autonomy.

3. The nurse is working with a client who needs to make adaptations to the home environment before the client can safety return home. Which of the following principles are important to consider? (Select all that apply.)

ANS: A, B, D, E

It is important to make changes in the client’s home environment to keep him or her as independent as possible, yet still consider the client’s financial resources. Whenever possible, the client should be the final decision maker in the types of changes to be made. The nurse should consider the client’s physical strengths and remaining functional abilities, not just the disabilities. It is important to educate family caregivers about the importance of preserving client autonomy so they can be supportive of the client.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Unintentional injury and violence is the number 5 cause of death in all Americans. b. Injuries are the leading cause of death in people aged 1–44 years. c. Injuries are the leading cause of disability in people of all age-groups. d. Violence and injury lead to higher medical costs and loss of productivity e. Sex, race, and socioeconomic status are important variables in violence effect.

4. A student is preparing a presentation on violence in the community setting. What information does the student include in this presentation? (Select all that apply.)

ANS: B, C, D

Injuries are the leading cause of death in people 1–44 years of age and the leading cause of disability in people of all ages, regardless of race, sex, or socioeconomic status. Violence and injury lead to higher medical costs and loss of productivity. Unintentional injury and violence are in the top 15 leading killers of Americans of all ages.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Following the caregiver around b. Going into the same room frequently c. Walking without an obvious purpose d. Frequent fidgeting while sitting e. Looking for “missing” people or pets

5. The nurse is educating a family caregiver on signs that indicate the client might be at risk for wandering. What information does the nurse include? (Select all that apply.)

ANS: A, B, C, E

Shadowing the caregiver; going to the same place repeatedly; walking without an obvious purpose; and looking for “missing” people, places, and pets all are signs the client is at risk for wandering. Continuous moving, pacing, or walking is a sign, however; fidgeting while sitting is not.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Store medications in the parent’s bedroom and keep the children out. b. Get down on the floor to look at the environment from the children’s view. c. Place safety plugs in the electrical outlets throughout the house. d. Using a night light in the children’s bathroom. e. Store guns in a locked safe and ammunition in a separate locked environment.

6. The home care nurse is visiting an adult client who has two young children under the age of 4. What strategy can the nurse teach the client to best protect the children from hazards in their home? (Select all that apply.)

ANS: B, C, D, E

The nurse instructs the parents or caregivers to get down on the floor and look at the environment from the children’s view to identify dangers present in the home. Telling the children they cannot enter the adult’s bedroom is impractical and if they found the medication, they might ingest it. Safety plugs are important to cover the electrical outlets. A night light in the children’s bathroom takes care of a specific time period in a specific place which can be helpful at night. Guns and ammunition should be stored separately in locked containers.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation

MATCHING a. May cause hypotension if taken with blood pressure medications. b. May cause falls when taken at night and client has urgent nocturia. c. May cause sedation and confusion at any time these are taken. d. May cause orthostatic hypotension or dizziness.

Match the type of medication to its safety hazard.

1. Diuretics

2. Antihypertensives

3. Opioid pain medication

4. Antidysrhythmics

1. ANS: B DIF: Cognitive Level: Remembering

OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment

MSC: Diuretics cause urination, which can be urgent. If the client takes the diuretic at night, he or she is at risk for falling due to rushing to the bathroom.

2. ANS: D DIF: Cognitive Level: Remembering

OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment

MSC: When blood pressure is lowered, the client can experience orthostatic hypotension and/or dizziness, both of which can contribute to falling.

3. ANS: C DIF: Cognitive Level: Remembering

OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment

MSC: Opioids often lead to sedation and confusion, which not only put clients at risk for falling, but also for other injuries if they are doing something that requires them to remain alert.

4. ANS: A DIF: Cognitive Level: Remembering

OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment

MSC: Antidysrhythmics and antihypertensives often cause dizziness when taken together.

Match the risk with an appropriate intervention a. Install broad-beam lighting. b. Paint surfaces with non-glossy paint. c. Install a shelf by the door client uses most often. d. Complete a pill count weekly. e. Dispose of medications crushed and mixed with cat litter.

5. Client has difficulty seeing clearly due to glare.

6. Client living alone may have cognitive deterioration.

7. Client has pets and children often visit.

8. Client gets fatigued and has near-falls.

9. Client enjoys short night time walks.

5. ANS: B DIF: Cognitive Level: Remembering

OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation

MSC: Satin and non-glossy paints and finishes will reduce glare from walls, and on countertops and cabinets.

6. ANS: D DIF: Cognitive Level: Remembering

OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation

MSC: If the nurse suspects the client who is self-administering medications has some cognitive impairment, a weekly pill count will help validate that medications are being taken correctly.

7. ANS: E DIF: Cognitive Level: Remembering

OBJ: NCLEX: Safe and Effective Care Environment