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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 nurse's priority is to assess the patient to determine the cause of sudden confusion and agitation. This may be due to various reasons such as hypoxia, hypoglycemia, infection, or medication side effects. Assessing the patient's vital signs, oxygen saturation, blood glucose level, and reviewing medication administration can help identify the underlying cause. Gathering restraint supplies (B) should not be the initial action as it may not address the root cause of the confusion and can lead to further agitation. Trying alternatives to restraint (C) is important, but assessing the patient should come first. Calling the healthcare provider for a restraint order (D) should only be considered after other interventions have been attempted.
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The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.)
- A. Where did you fall?
- B. What time did the fall occur?
- C. What were you doing when you fell?
- D. What types of injuries occurred after the fall?
- E. Did you obtain an electronic safety alert device after the fall?
- F. What are your medical problems that may have caused the fall?
Correct Answer: A, B, C, D
Rationale: The correct answers are A, B, C, and D. The SPLATT acronym stands for Symptoms, Previous falls, Location, Activity, Time, and Trauma. Therefore, the nurse should ask where the fall happened (A), what the patient was doing when they fell (C), and what types of injuries occurred after the fall (D) to assess the circumstances surrounding the fall. Asking about the time of the fall (B) helps determine if there are any time-related factors contributing to the fall. These questions provide crucial information for assessing the patient's risk factors and potential interventions. Choices E and F are incorrect because they do not directly pertain to the SPLATT components and may not provide as relevant information for assessing the fall risk in this situation.
The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring?
- A. Tile floors, cold food, scratchy linen, and noisy alarms
- B. Dirty floors, hallways blocked, medication room locked, and alarms set
- C. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach
- D. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly
Correct Answer: D
Rationale: The correct answer is D because it includes examples of safety risks that directly impact patient well-being. Wet floors unmarked can lead to slips and falls. Patient pinching fingers in the door is a physical hazard. Failure to use a lift for a patient can cause injury to both the patient and staff. Alarms not functioning properly can delay response to emergencies.
Explanation for other choices:
A: Tile floors, cold food, scratchy linen, and noisy alarms are not direct safety risks that pose immediate harm to patients.
B: Dirty floors, blocked hallways, and alarms set are not specific examples of patient safety risks.
C: Carpeted floors, ice machine empty, and call light in reach are not significant safety risks compared to the examples in choice D.
Which activity will cause the nurse to monitor for equipment-related accidents?
- A. Uses a patient-controlled analgesic pump
- B. Uses a computer-based documentation record
- C. Uses a measuring device that measures urine
- D. Uses a manual medication-dispensing device
Correct Answer: A
Rationale: The correct answer is A because using a patient-controlled analgesic pump involves complex equipment that can malfunction or be misused, leading to potential accidents like overmedication or pump failure. Monitoring is crucial to prevent harm. Choices B and C involve routine equipment use without high risk for accidents. Choice D is more straightforward and less prone to accidents compared to the complex analgesic pump.
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 question is most important as hearing loss is a common age-related physiological change that can affect safety during emergencies. Tornado sirens are crucial for alerting individuals to seek shelter.
Summary of other choices:
B: Reading ability is important but not directly related to safety.
C: Taste changes are common with age but do not impact safety significantly.
D: Difficulty opening jars may occur with age but is not as critical for safety in emergencies.
In this context, asking about hearing the tornado sirens is the most relevant question for ensuring the safety of older adults in an assisted-living facility.
A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?
- A. Check on the patient once a shift.
- B. Encourage visitors in the early evening.
- C. Place all four side rails in the 'up' position.
- D. Keep the patient on fall risk until discharge.
Correct Answer: D
Rationale: The correct answer is D because keeping the patient on fall risk until discharge ensures continuous monitoring and implementation of fall precautions. Checking on the patient once a shift (Option A) is not enough for a high fall risk patient. Encouraging visitors in the early evening (Option B) may distract the patient and increase the risk of falls. Placing all four side rails in the 'up' position (Option C) can lead to entrapment and is not recommended. Keeping the patient on fall risk until discharge (Option D) ensures consistent vigilance and preventive measures.