A home health nurse is inspecting a clients residence for electrical hazards as part of the agencys quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?
- A. An IV pump is plugged into an outlet near a sink.
- B. A lamp with a short cord is used in the bedroom.
- C. A television is plugged into a surge protector.
- D. The client uses a nightlight in the hallway.
Correct Answer: A
Rationale: Correct Answer: A. An IV pump is plugged into an outlet near a sink.
Rationale: Plugging an IV pump near a sink poses a significant risk of electrical shock due to water exposure. Water conducts electricity and can lead to electrocution. This situation directly violates electrical safety guidelines.
Summary of other choices:
B. A lamp with a short cord in the bedroom: While a short cord may not be ideal, it does not pose an immediate safety hazard unless it is frayed or damaged.
C. A television plugged into a surge protector: This is a safe practice as surge protectors help prevent damage from power surges and do not pose a direct safety hazard.
D. The client uses a nightlight in the hallway: Nightlights are commonly used for safety and do not typically pose an electrical hazard if used correctly.
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A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Right lower quadrant pain
- B. Rebound tenderness
- C. Nausea and vomiting
- D. Elevated blood glucose
- E. Hypotension
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.
A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema? (Select all that apply.)
- A. Excessive somnolence
- B. Epistaxis
- C. Pink frothy sputum
- D. Tachypnea
- E. Urinary frequency
Correct Answer: A, C, D
Rationale: The correct answers are A, C, and D. Excessive somnolence (A) can indicate inadequate oxygenation due to pulmonary edema. Pink frothy sputum (C) is a classic sign of pulmonary edema, caused by fluid leaking into the lungs. Tachypnea (D) is the body's response to decreased oxygen levels in the blood, characteristic of pulmonary edema. Epistaxis (B) and urinary frequency (E) are not typically associated with pulmonary edema. In summary, the correct answers reflect respiratory distress and inadequate oxygenation, while the incorrect choices are unrelated symptoms.
A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should identify that which of the following findings is a manifestation of hyperglycemia?
- A. Sweating
- B. Increased thirst
- C. Shakiness
- D. Decreased urination
Correct Answer: B
Rationale: Correct Answer: B - Increased thirst
Rationale: Hyperglycemia results in elevated blood glucose levels, which leads to osmotic diuresis and fluid loss, causing increased thirst. Sweating (A) is more commonly associated with hypoglycemia. Shakiness (C) is a symptom of hypoglycemia due to low blood sugar levels. Decreased urination (D) is not a typical manifestation of hyperglycemia as it is more commonly associated with conditions like dehydration or kidney issues.
A nurse is teaching a client who is scheduled to receive radioactive iodine therapy for treatment of hyperthyroidism. Which of the following instructions should the nurse include in the teaching?
- A. Avoid dairy products.
- B. Use disposable utensils for meals.
- C. Sleep next to family members.
- D. Increase iodine-rich foods in your diet.
Correct Answer: B
Rationale: The correct answer is B: Use disposable utensils for meals. This is important to prevent contamination of utensils by the radioactive iodine, which can be harmful to others. A - Avoiding dairy products is irrelevant for radioactive iodine therapy. C - Sleeping next to family members can expose them to radiation. D - Increasing iodine-rich foods can interfere with the therapy. Thus, B is the most appropriate instruction to include in the teaching.
A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
- A. Observing for symmetrical chest rise and fall
- B. Auscultating bilateral breath sounds
- C. Using an end-tidal COâ‚‚ detector
- D. Checking for condensation in the ET tube
Correct Answer: C
Rationale: The correct answer is C: Using an end-tidal CO2 detector. This method is the most reliable for verifying ET tube placement because it directly measures the presence of CO2 in exhaled breath, confirming that the tube is in the trachea. This is crucial to prevent inadvertent esophageal intubation. Observing for symmetrical chest rise and fall (A) can be misleading as it can occur even with esophageal intubation. Auscultating bilateral breath sounds (B) can also be unreliable as breath sounds may be heard even if the tube is in the esophagus. Checking for condensation in the ET tube (D) is not a reliable method for verifying placement as condensation can occur regardless of tube placement.
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