Nokea
A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?
- A. Risk for injury: Check on patient every 15 minutes.
- B. Risk for suffocation: Place 'Oxygen in Use' sign on door.
- C. Disturbed body image: Encourage patient to express concerns about body.
- D. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.
Correct Answer: A
Rationale: The correct answer is A: Risk for injury: Check on patient every 15 minutes.
Rationale:
1. Priority: Safety of the patient is the top priority, as the patient is at risk for injury due to attempts to remove essential medical devices.
2. Regular monitoring: Checking on the patient every 15 minutes allows for timely intervention if the patient attempts to remove the oxygen cannula or urinary catheter.
3. Prevention of harm: By checking frequently, nurses can prevent potential harm such as hypoxia or catheter-related complications.
4. Immediate action: This intervention addresses the immediate safety concern and ensures the patient's well-being.
Incorrect choices:
B: Risk for suffocation: Placing a sign does not directly address the patient's behavior.
C: Disturbed body image: Patient's behavior is not related to body image concerns.
D: Deficient knowledge: Explaining the purpose does not address the immediate safety risk.
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The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. Which priority concern will require collaboration with social services to address the patient's health care needs?
- A. The electricity was turned off 3 days ago.
- B. The water comes from the county water supply.
- C. A son and family recently moved into the home.
- D. This home is not furnished with a microwave oven.
Correct Answer: A
Rationale: The correct answer is A. The priority concern that requires collaboration with social services is the electricity being turned off 3 days ago. This is crucial because without electricity, the patient's access to essential medical devices, such as a refrigerator for storing medications or a nebulizer for breathing treatments, is compromised. Social services can help address this issue by connecting the patient with resources for utility assistance or temporary housing.
Choice B is incorrect because access to county water supply is not directly related to the patient's immediate health care needs in this scenario. Choice C is also incorrect as the son and family moving in is not a priority concern requiring collaboration with social services. Choice D is not a priority concern either, as the lack of a microwave oven does not impact the patient's health care needs significantly.
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.
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.
A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?
- A. Every December is the time to change batteries on the carbon monoxide detector.
- B. I will schedule an appointment with a chimney inspector next week.
- C. If I feel dizzy when using the heater, I need to have it inspected.
- D. When it is cold outside in the winter, I will use a nonvented furnace.
Correct Answer: D
Rationale: The correct answer is D because using a nonvented furnace can lead to carbon monoxide poisoning, which is a significant safety hazard. The nurse should follow up to educate the patient on the dangers of using a nonvented furnace and recommend safer heating alternatives. Choice A is correct as it emphasizes the importance of changing carbon monoxide detector batteries annually. Choice B is correct as scheduling a chimney inspection is a proactive safety measure. Choice C is correct as feeling dizzy while using a heater can indicate a potential issue. Choices E, F, and G are not applicable in this context.
The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.)
- A. Close all doors.
- B. Note evacuation routes.
- C. Note oxygen shut-offs.
- D. Move bedridden patients in their bed.
- E. Wait until the fire department arrives to act.
- F. Use type B fire extinguishers for electrical fires.
Correct Answer: A, B, C, D
Rationale: The correct actions for the nurse to take in this situation are A, B, C, and D. Closing all doors helps contain the fire and smoke. Noting evacuation routes ensures a safe exit plan. Knowing oxygen shut-offs prevents fire hazards. Moving bedridden patients in their beds aids in their evacuation. Choice E is incorrect because waiting for the fire department delays necessary actions. Choice F is incorrect as type B fire extinguishers are not suitable for electrical fires, which require type C extinguishers.