Nokea
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C: Using an old space heater may pose a safety risk due to outdated technology and potential malfunctions, making it unsafe to use.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
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The nurse is performing the 'Timed Get Up and Go (TUG)' assessment. Which actions will the nurse take? (Select all that apply.)
- A. Ranks a patient as high risk for falls after patient takes 18 seconds to complete.
- B. Teaches patient to rise from a straight back chair using arms for support.
- C. Instructs the patient to walk 10 feet as quickly and safely as possible.
- D. Observes for unsteadiness in patient's gait.
- E. Begins counting after the instructions.
Correct Answer: C,D,F
Rationale: The correct answers are C, D, and F.
C: Instructing the patient to walk 10 feet quickly and safely is a key component of the TUG test to assess mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is important to evaluate balance and stability during the test.
F: Beginning counting after giving instructions ensures an accurate timing of the patient's performance.
Incorrect choices:
A: Ranking a patient as high risk for falls after taking 18 seconds is not accurate as the cutoff time for increased fall risk is typically 12-14 seconds.
B: Teaching the patient to rise from a straight back chair using arms for support is not part of the TUG assessment and may not provide accurate information about the patient's mobility and fall risk.
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 the use of medical equipment that can malfunction or be misused, potentially leading to accidents such as medication overdose. The nurse needs to monitor the equipment closely to ensure it is functioning properly and the patient is using it correctly. Choices B, C, and D do not involve equipment that poses a high risk of accidents if not monitored closely. Computer-based documentation records, measuring devices for urine, and manual medication-dispensing devices are all important tools for nurses, but they are less likely to result in equipment-related accidents compared to a patient-controlled analgesic pump.
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 assesses a home after the birth of an infant. A toddler also lives in the home. Which finding requires follow-up?
- A. Plastic grocery bags stored under the counter.
- B. Electric outlets are covered.
- C. No bumper pads in crib.
- D. Crib slats are 5 cm apart.
Correct Answer: A
Rationale: The correct answer is A because plastic grocery bags stored under the counter pose a suffocation hazard for the toddler. This finding requires follow-up to ensure the bags are kept out of reach. Choices B, C, and D are not immediate safety concerns. Electric outlets covered prevent electrical hazards, no bumper pads in the crib reduce the risk of Sudden Infant Death Syndrome, and crib slats being 5 cm apart meet safety standards.
A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.)
- A. Health care provider orders restraints prn (as needed).
- B. Health care provider writes the type and location of the restraint.
- C. Health care provider renews orders for restraints every 24 hours.
- D. Health care provider performs a face-to-face assessment prior to the order.
- E. Health care provider specifies the duration and circumstances under which the restraint will be used.
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. Choice B ensures the type and location of the restraint are specified, promoting safe application. Choice D, the face-to-face assessment, is crucial to assess the need for restraints. Choice E, specifying duration and circumstances, ensures restraints are used only when necessary. Choice A is incorrect as PRN orders can lead to inappropriate use. Choice C is incorrect as orders should be renewed every 2 hours, not 24.