Safe and Effective Care Environment 3 — Questions and Answers
Question 1: A nurse is caring for a client who is at high risk for falls. Which intervention is the priority?
- Apply a vest restraint to keep the client in bed
- Keep the bed in the lowest position and call light within reach (Correct answer)
- Administer a sleep aid to prevent the client from wandering at night
- Instruct the client's family to remain at the bedside at all times
Correct answer: Keep the bed in the lowest position and call light within reach
For a client at high risk for falls, keeping the bed in the lowest position with all four side rails in appropriate position and the call light within reach is a cornerstone fall-prevention intervention. While all options may be part of a fall prevention plan, the bed in the lowest position directly reduces injury severity if a fall does occur. This is often the highest-priority structural/environmental safety measure.
Question 2: A nurse is administering medications and realizes the client's arm band is missing. What should the nurse do?
- Ask the client to state their name and administer the medication
- Check the room number and administer if the name matches the MAR
- Do not administer medication; replace and verify the arm band first (Correct answer)
- Ask a colleague who knows the client to confirm identity verbally
Correct answer: Do not administer medication; replace and verify the arm band first
Client identification before medication administration is a fundamental safety requirement (Joint Commission National Patient Safety Goal). Without a readable arm band, the nurse cannot safely verify identity. The nurse must NOT administer medications until the client is properly identified using at least two identifiers (name + date of birth or medical record number). The arm band must be replaced and verified first.
Question 3: A nurse is caring for a client in soft wrist restraints. Which assessment must the nurse perform and document every two hours?
- Client's pain level using the numeric rating scale
- Neurovascular status, skin integrity, and repositioning needs (Correct answer)
- Blood pressure and pulse oximetry
- Level of consciousness using the Glasgow Coma Scale
Correct answer: Neurovascular status, skin integrity, and repositioning needs
When a client is in restraints, the nurse must assess and document every two hours (or more frequently per facility policy): neurovascular status of the restrained extremity (circulation, sensation, movement), skin integrity under the restraint, respiratory status, and offer range-of-motion exercises, repositioning, toileting, and hydration. Neurovascular checks (circulation, sensation, movement) are the mandatory safety assessment to prevent injury from impaired circulation.
Question 4: A nurse receives a telephone order from a physician for a new medication. Which is the correct procedure?
- Write the order, implement it, and have the provider sign it on their next visit
- Refuse telephone orders — only written or electronic orders are acceptable
- Write the order, read it back to the provider for verification, then implement (Correct answer)
- Implement the order immediately and document it later to save time
Correct answer: Write the order, read it back to the provider for verification, then implement
When receiving a verbal or telephone order, the nurse must use the "read-back" technique: write the order down, then read it back to the provider verbatim to verify accuracy, and receive confirmation. This closed-loop communication process is required by The Joint Commission to prevent transcription errors and miscommunication. The order must be signed by the provider within the time frame specified by facility policy (typically 24 hours).
Question 5: A nurse is caring for a client who speaks limited English and requires teaching about a new diagnosis. Which action best promotes safe, effective client education?
- Ask the client's family member to interpret during the teaching session
- Provide written materials in English and have the client review them independently
- Use a qualified medical interpreter for the teaching session (Correct answer)
- Speak loudly and slowly and use simple English words
Correct answer: Use a qualified medical interpreter for the teaching session
Using a qualified medical interpreter (in person or via telephone/video) is the standard of care for clients with limited English proficiency. Family members and friends should NOT be used as interpreters because they may omit, change, or misinterpret medical information — compromising client safety and confidentiality. Federal law (Title VI of the Civil Rights Act) requires healthcare facilities to provide language assistance services.
Question 6: A nurse is caring for a client who is confused and trying to climb out of bed. After attempting least-restrictive measures, the nurse applies a physical restraint. Which action must the nurse take immediately after applying the restraint?
- Apply padded mitts to prevent skin breakdown under the restraint
- Notify the family that a restraint has been applied
- Obtain a provider order for the restraint immediately (Correct answer)
- Document the restraint in the chart as the first priority
Correct answer: Obtain a provider order for the restraint immediately
After applying a physical restraint, the nurse must obtain a provider order immediately (or as soon as possible per facility policy — in most cases within 1 hour). Applying a restraint without an order is considered a form of false imprisonment. While least-restrictive measures should be attempted first, once a restraint is applied, timely provider order, assessment, and documentation are all required. The order is the immediate next step after application.
Safe and Effective Care Environment 3
A nurse is caring for a client who is at high risk for falls.
Which intervention is the priority?