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The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.)
- A. One family member has gone to lunch.
- B. Patient is placed in bilateral wrist restraints at 0815.
- C. Bilateral radial pulses present 2+ hands warm to touch.
- D. Straps with quick-release buckle attached to bed side rails.
- E. Attempts to distract the patient with television are unsuccessful.
- F. Released from restraints active range-of-motion exercises completed.
Correct Answer: B, C, E, F
Rationale: The correct answers are B, C, E, and F.
B: Documenting the time and type of restraints ensures accurate monitoring and prevents complications.
C: Checking pulses and assessing extremities' warmth is crucial to ensure circulation and prevent injury.
E: Documenting unsuccessful attempts to distract the patient helps assess effectiveness of interventions.
F: Noting the completion of range-of-motion exercises ensures patient safety and compliance with protocols.
Other options are irrelevant or do not directly relate to the safe care of a patient in restraints.
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A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident?
- A. Pathogenic asepsis
- B. Medical asepsis
- C. Surgical asepsis
- D. Clean asepsis
Correct Answer: C
Rationale: The correct answer is C: Surgical asepsis. During urinary catheter insertion, surgical asepsis is crucial to prevent infection and other procedure-related accidents. Surgical asepsis involves using sterile techniques to minimize the risk of introducing pathogens. The nurse will follow strict protocols such as wearing sterile gloves, using sterile equipment, and maintaining a sterile field. This technique ensures that the urinary catheter is inserted in a sterile environment, reducing the risk of infection. Pathogenic asepsis (A) focuses on destroying pathogens, not preventing their entry during a procedure. Medical asepsis (B) aims to reduce the number of pathogens but does not provide the level of sterility needed for urinary catheter insertion. Clean asepsis (D) involves cleanliness but does not meet the sterile requirements of urinary catheter insertion.
The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one?
- A. Pull the alarm.
- B. Remove the patient.
- C. Use the fire extinguisher.
- D. Close doors and windows.
Correct Answer: A
Rationale: The correct order is A: Pull the alarm. In case of a fire, alerting others is the first priority to ensure everyone's safety. This step will notify the fire department and initiate evacuation procedures. Removing the patient (B) should be done after sounding the alarm to prevent harm. Using the fire extinguisher (C) comes after ensuring the alarm is activated. Closing doors and windows (D) is important to contain the fire but should be done after alerting others and removing the patient.
An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient?
- A. Positions patient's buttocks close to the front of wheelchair seat
- B. Backs wheelchair into elevator
- C. leading with large rear wheels first
- D. Places locked wheelchair on same side of bed as patient's weaker side
- E. Unlocks wheelchair for easy maneuverability when patient is transferring
Correct Answer: B
Rationale: The correct answer is B because backing the wheelchair into the elevator allows the nurse to maintain visual contact with the patient and ensures a safe exit from the elevator. This also prevents any potential accidents or injuries that may occur if the wheelchair is pushed forward into the elevator, where the nurse may not be able to see obstacles or other individuals. Positioning the patient's buttocks close to the front of the wheelchair seat (choice A) may cause discomfort and pressure ulcers. Leading with large rear wheels first (choice C) can be dangerous as it may cause the wheelchair to tip over. Placing a locked wheelchair on the same side of the bed as the patient's weaker side (choice D) restricts the patient's ability to access the wheelchair. Unlocking the wheelchair for easy maneuverability (choice E) is important but not directly related to safe transport in this context.
The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.)
- A. Water outdoor plants with a nozzle and hose.
- B. Walk to the mailbox in the summer.
- C. Encourage yearly eye examinations.
- D. Use bathtubs without safety strips.
- E. Keep pathways clutter free.
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
- B: Walking to the mailbox in the summer promotes physical activity and maintains strength and balance, reducing fall risk.
- C: Yearly eye examinations help detect vision problems that can increase fall risk.
- E: Keeping pathways clutter-free prevents tripping hazards, reducing the risk of falls.
Other choices are incorrect:
- A: Watering outdoor plants with a nozzle and hose does not directly impact fall prevention.
- D: Using bathtubs without safety strips increases the risk of slipping and falling.
- F, G: No additional choices provided.
During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
- A. The patient is oriented.
- B. The patient takes a hypnotic.
- C. The patient walks 2 miles a day.
- D. The patient recently became widowed.
Correct Answer: B
Rationale: The correct answer is B: The patient takes a hypnotic. Patients taking hypnotic medications are at an increased risk for falls due to the sedative effects of these drugs, causing dizziness, impaired balance, and confusion. This increases the likelihood of accidents and falls.
Incorrect Choices:
A: The patient is oriented. Being oriented does not necessarily indicate a decreased risk for falls.
C: The patient walks 2 miles a day. Regular exercise is beneficial for overall health but does not directly correlate with fall risk.
D: The patient recently became widowed. While emotional distress can affect a person's well-being, it does not directly indicate an increased risk for falls.