The nurse is performing the “Timed Get Up and Go (TUG)†assessment. Which actions will the nurse take? (Select all that apply.)
- A. Ranks a patient as high risk for falls after patient takes 18 seconds to complete
- B. Teaches patient to rise from straight back chair using arms for support
- C. Instructs the patient to walk 10 feet as quickly and safely as possible
- D. Observes for unsteadiness in patient's gait
- E. Begins counting after the instructions
- F. Allows the patient a practice trial.
Correct Answer: C, D, F
Rationale: The correct answers are C, D, and F.
C: Instructing the patient to walk 10 feet quickly and safely is a key step in the TUG assessment to evaluate mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is crucial to assess balance and risk of falls during the TUG assessment.
F: Allowing the patient a practice trial helps ensure that they understand the instructions and can perform the task accurately during the actual assessment.
These actions are essential for a comprehensive and accurate evaluation of the patient's mobility and fall risk during the Timed Get Up and Go assessment.
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A home health nurse assesses a home after the birth of an infant. A toddler also lives in the home. Which finding requires follow-up?
- A. Plastic grocery bags stored under the counter.
- B. Electric outlets are covered.
- C. No bumper pads in crib.
- D. Crib slats are 5 cm apart.
Correct Answer: A
Rationale: The correct answer is A because plastic grocery bags stored under the counter pose a suffocation hazard for the toddler. This finding requires follow-up to ensure the bags are kept out of reach. Choices B, C, and D are not immediate safety concerns. Electric outlets covered prevent electrical hazards, no bumper pads in the crib reduce the risk of Sudden Infant Death Syndrome, and crib slats being 5 cm apart meet safety standards.
A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.)
- A. Smoking in bed helps me relax and fall asleep.
- B. We never leave candles burning when we are gone.
- C. We use the same space heater my grandparents used.
- D. We use the RACE method when using the fire extinguisher.
- E. There is a fire extinguisher in the kitchen and garage workshop.
Correct Answer: A, C, D
Rationale: The correct answers are A, C, D.
A: Smoking in bed poses a significant fire hazard due to the risk of falling asleep while smoking, leading to potential ignition of bed linens.
C: Using an old space heater may increase the risk of malfunction and fire hazards, as older models may not have modern safety features.
D: Using the RACE method for fire extinguisher use (Rescue, Alarm, Contain, Extinguish) is incorrect; the correct method is PASS (Pull, Aim, Squeeze, Sweep).
B, E: Leaving candles burning and having fire extinguishers accessible are good fire safety practices.
In summary, choices A, C, and D warrant intervention due to the increased risk of fire hazards, while choices B and E demonstrate good fire safety habits.
A confused patient is restless and continues to remove oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention?
- A. Risk for injury: Check on patient every 15 minutes.
- B. Risk for suffocation: Place “Oxygen in Use†sign.
- C. Disturbed body image: Encourage patient expression.
- D. Deficient knowledge: Explain oxygen therapy.
Correct Answer: A
Rationale: The correct answer is A: Risk for injury: Check on patient every 15 minutes. This is the priority nursing diagnosis because the patient is at risk for harm due to removing essential medical equipment. Continuous monitoring can prevent potential injuries. Choice B is incorrect as simply placing a sign does not actively address the patient's behavior. Choice C is incorrect as the patient's actions are not related to body image. Choice D is incorrect as the patient's behavior is not due to a lack of knowledge about oxygen therapy. Monitoring the patient closely is crucial in ensuring their safety and preventing harm in this situation.
A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session?
- A. Proper fit of a bicycle helmet.
- B. Proper fit of soccer shin guards.
- C. Proper fit of swimming goggles.
- D. Proper fit of baseball sliding shorts.
Correct Answer: A
Rationale: The correct answer is A: Proper fit of a bicycle helmet. This is the most important safety item to include because head injuries from bicycle accidents can be life-threatening. Properly fitting helmets can significantly reduce the risk of head injuries. Soccer shin guards, swimming goggles, and baseball sliding shorts are important for their respective activities, but they do not have the same potential life-saving impact as a bicycle helmet. It is crucial for the nurse to emphasize the importance of wearing a properly fitting helmet to prevent head injuries during biking.
A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?
- A. Wash hands
- B. Wash wound
- C. Wear gloves
- D. Wear eye protection
Correct Answer: A
Rationale: The correct answer is A: Wash hands. This technique is crucial in preventing the transmission of pathogens because hands are a common mode of pathogen spread. Washing hands effectively removes pathogens and reduces the risk of infection. Choice B (Wash wound) is important for wound care but not as effective in preventing transmission of pathogens. Choice C (Wear gloves) is important for personal protection but does not address the primary mode of transmission. Choice D (Wear eye protection) is not directly related to preventing transmission through hand hygiene. It is essential to prioritize hand hygiene as the most effective method of preventing the spread of pathogens.