Nokea
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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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. D is important as it addresses the need for the family to know what to do if the seizure does not stop, such as calling emergency services. E is crucial as it focuses on the post-seizure care, which includes reorienting and reassuring the patient. A is incorrect as restraining a patient during a seizure can be harmful. B is incorrect as moving the patient during a seizure can lead to injury. C is incorrect as inserting a tongue depressor can also be harmful and is not recommended during a seizure.
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.
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.
Correct Answer: B,C,E,F
Rationale: Correct Answer: B, C, E, F
Rationale:
B: Documenting the specific time and type of restraints applied ensures accurate monitoring and compliance with protocols.
C: Noting the presence and quality of radial pulses helps in assessing circulation and preventing complications related to restraints.
E: Documenting unsuccessful attempts to distract the patient with television indicates efforts made to address the patient's needs.
F: Recording any interventions or actions taken is crucial for continuity of care and legal documentation.
Summary:
A: Irrelevant to the patient's care in restraints.
D: Focuses on the equipment used rather than patient assessment.
G: No information provided to evaluate this option.
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.
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.