Nokea
The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?
- A. Are you able to hear the tornado sirens in your area?
- B. Are you able to read your favorite book?
- C. Are you able to taste spices like before?
- D. Are you able to open a jar of pickles?
Correct Answer: A
Rationale: The correct answer is A: "Are you able to hear the tornado sirens in your area?" This is the most important question because hearing loss is a common age-related physiological change that can affect safety, especially during emergencies like tornadoes. The ability to hear warning signals is crucial for timely response and ensuring the safety of older adults. Choices B, C, and D are not as critical for safety concerns compared to the ability to hear warning sirens. Older adults may use aids for reading, cooking, or opening jars, but compromised hearing can directly impact their ability to respond to emergencies effectively.
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The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working?
- A. The patient continues to get up from the chair at the nurses' station.
- B. The patient gets restless when the sitter leaves for lunch.
- C. The patient folds three washcloths over and over.
- D. The patient apologizes for being 'such a bother.'
Correct Answer: C
Rationale: The correct answer is C because the patient folding three washcloths over and over indicates engagement in a task, showing decreased restlessness or agitation. This behavior suggests the patient is able to focus on a repetitive and soothing activity, indicating successful use of alternatives to restraint. Choice A shows continued restlessness, choice B demonstrates dependence on the sitter, and choice D indicates the patient's emotional response, none of which directly reflect the effectiveness of the alternative intervention.
The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?
- A. 60° to 64° F
- B. 65° to 75° F
- C. 15° to 17° C
- D. 25° to 28° C
Correct Answer: B
Rationale: The correct answer is B: 65° to 75° F. This temperature range is ideal for a patient experiencing respiratory distress as it helps maintain a comfortable environment without being too cold or too warm. Lower temperatures (choice A) can exacerbate breathing difficulties, while the temperature range in Celsius (choice C) is too low for comfort. The temperature range in choice D is too warm and may cause discomfort for the patient. It is important to maintain a moderate temperature to assist the patient in breathing comfortably.
The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take?
- A. Assess the patient.
- B. Gather restraint supplies.
- C. Try alternatives to restraint.
- D. Call the health care provider for a restraint order.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient. The priority action is to assess the patient to determine the underlying cause of the sudden confusion and agitation. This will help the nurse identify any medical issues or discomfort causing the behavior, such as hypoxia, infection, or medication side effects. By assessing the patient first, the nurse can address the root cause of the behavior and implement appropriate interventions, which may include addressing the patient's needs, providing comfort measures, or involving other healthcare team members as needed. Gathering restraint supplies (B) should not be the initial action as it does not address the underlying cause of the behavior. Trying alternatives to restraint (C) is important but should come after assessing the patient. Calling the healthcare provider for a restraint order (D) should only be considered after other interventions have been attempted.
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.
The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing?
- A. Young infant
- B. Toddler
- C. Preschooler
- D. Adolescent
Correct Answer: B
Rationale: The correct answer is B: Toddler. Toddlers are at highest risk for lead poisoning due to their habit of putting objects in their mouths. Lead exposure can come from old paint, soil, or water. Young infants have less exposure due to limited mobility. Preschoolers are less at risk as they are less likely to engage in mouthing behaviors. Adolescents have lower risk as they are less likely to come into contact with lead sources.