Nokea
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. Carbon monoxide is a colorless, odorless gas that can be deadly if inhaled in high concentrations. The other choices demonstrate good safety practices such as changing batteries on detectors, scheduling chimney inspections, and recognizing symptoms of heater issues. Using a nonvented furnace is the only unsafe practice mentioned, hence requiring immediate follow-up to educate the patient on the dangers of carbon monoxide poisoning.
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A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?
- A. Remove the restraint.
- B. Place a blanket over the feet.
- C. Immediately do a complete head-to-toe neurologic assessment.
- D. Take the patient's blood pressure pulse temperature and respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Remove the restraint. The blue color in the toes indicates impaired circulation, possibly due to the ankle restraint being too tight. Removing the restraint will allow blood flow to return to the toes and prevent further complications such as tissue damage or necrosis. Choice B is incorrect as it does not address the underlying circulation issue. Choice C is not necessary unless there are other concerning neurological symptoms present. Choice D is important for overall assessment but does not address the immediate issue of impaired circulation.
A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?
- A. 55 years old
- B. 20/20 vision
- C. Urinary continence
- D. Orthostatic hypotension
Correct Answer: D
Rationale: The correct answer is D: Orthostatic hypotension. This finding indicates a drop in blood pressure upon standing, which can lead to dizziness and falls. A 55-year-old age (choice A) does not inherently indicate fall risk. 20/20 vision (choice B) does not directly correlate with fall risk. Urinary continence (choice C) is not a significant fall risk factor. The presence of orthostatic hypotension (choice D) is a clear indicator of potential falls due to the risk of dizziness and loss of balance.
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: Keep the patient on fall risk until discharge. This is because fall precautions should be maintained throughout the patient's stay to ensure their safety. Checking on the patient once a shift (A) may not be sufficient to prevent falls. Encouraging visitors in the early evening (B) could distract the patient and increase fall risk. Placing all four side rails in the 'up' position (C) can lead to entrapment or injury. Therefore, the best practice is to keep the patient on fall risk until discharge to maintain a high level of vigilance and prevent falls effectively.
The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one?
- A. Pull the alarm.
- B. Remove the patient.
- C. Use the fire extinguisher.
- D. Close doors and windows.
Correct Answer: A
Rationale: The correct order is A: Pull the alarm. In case of a fire, alerting others is the first priority to ensure everyone's safety. This step will notify the fire department and initiate evacuation procedures. Removing the patient (B) should be done after sounding the alarm to prevent harm. Using the fire extinguisher (C) comes after ensuring the alarm is activated. Closing doors and windows (D) is important to contain the fire but should be done after alerting others and removing the patient.
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 answer includes choices B, D, and E. Choice B ensures that the type and location of the restraint are clearly specified, promoting safe and appropriate use. Choice D mandates a face-to-face assessment by the healthcare provider before ordering restraints, ensuring that the decision is based on a thorough evaluation of the patient's condition. Choice E is crucial as it requires the healthcare provider to specify the duration and circumstances of restraint use, helping prevent unnecessary or prolonged use. Choices A, C, F, and G are incorrect because relying on PRN orders (A) may lead to inconsistent and potentially unsafe application of restraints, renewing orders every 24 hours (C) may not adequately address the patient's changing needs, and the absence of specific details in choices F and G can result in ambiguity and misuse of restraints.