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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.
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A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?
- A. Identifies patient with one identifier before transporting to x-ray department
- B. Initiates an intravenous (IV) catheter using clean technique on the first try
- C. Uses medication bar coding when administering medications
- D. Obtains vital signs to place on a surgical patient's chart
Correct Answer: C
Rationale: The correct answer is C because using medication bar coding ensures the right medication is given to the right patient at the right time, aligning with National Patient Safety Goals to prevent medication errors. This process enhances patient safety by verifying the medication through scanning before administration.
Choice A may be a good practice, but it does not directly relate to a specific patient safety goal. Choice B focuses on IV catheter insertion technique, which is important but not specifically related to patient safety goals. Choice D is important for patient care but doesn't directly address medication safety.
The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family? (Select all that apply.)
- A. Demonstrate how to restrain the patient in the event of a seizure.
- B. Instruct the family to move the patient to a bed during a seizure.
- C. Teach the family how to insert a tongue depressor during the seizure.
- D. Discuss with the family steps to take if the seizure does not discontinue.
- E. Instruct the family to reorient and reassure the patient after consciousness is regained.
Correct Answer: D, E
Rationale: The correct answers are D and E.
For choice D, it is essential to discuss steps to take if the seizure does not stop as it ensures the family is prepared and knows when to seek medical help. This is crucial for the safety of the patient.
For choice E, instructing the family to reorient and reassure the patient after regaining consciousness helps provide emotional support and comfort, promoting a sense of security and reducing anxiety post-seizure.
Choices A, B, and C are incorrect as they involve unsafe practices that can harm the patient. Restraining the patient during a seizure can lead to injury, moving the patient during a seizure can also cause harm, and inserting a tongue depressor is not recommended during a seizure as it can obstruct the airway.
Therefore, choices D and E are the most appropriate interventions for the patient and family in this scenario.
The nurse is discussing threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?
- A. Smoking even at parties is not good for my body.
- B. Our campus is safe; we leave our dorms unlocked all the time.
- C. As long as I have only two drinks, I can still be the designated driver.
- D. I am young, so I can work nights and go to school with 2 hours' sleep.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Smoking is a significant threat to adult safety, increasing the risk of various health issues.
2. The statement acknowledges the harmful effects of smoking even in social settings, showing awareness of health risks.
3. It demonstrates understanding of personal responsibility for one's health and safety.
Summary:
B: Leaving dorms unlocked poses a safety risk, indicating a lack of understanding of safety concerns.
C: Drinking and driving, even with only two drinks, is unsafe and illegal, showing a lack of awareness.
D: Working nights with minimal sleep can lead to fatigue-related accidents, reflecting poor judgment on safety.
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.
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: Correct Answer: A, C, D
Rationale:
A: Smoking in bed is a significant fire hazard as it can lead to accidental fires if the individual falls asleep without extinguishing the cigarette. Intervening is crucial to prevent potential disasters.
C: Using an old space heater may pose a safety risk due to outdated technology and potential malfunctions, making it unsafe to use. Intervening is necessary to ensure the safety of the family.
D: Using the RACE method (Rescue, Alarm, Contain, Extinguish) during a fire emergency is important for effective response. Confirming that the family is aware of this method ensures proper handling of fire situations.
Summary:
B: Leaving candles burning unsupervised is a safety concern, but the family's practice of not doing so mitigates the risk.
E: Having fire extinguishers in accessible locations is a good practice for fire safety, indicating preparedness and prevention.
Overall, choices A, C, and D require