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A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session?
- A. Run wires under the carpet.
- B. Disconnect items before cleaning.
- C. Grasp the cord when unplugging items.
- D. Use masking tape to secure cords to the floor.
Correct Answer: B
Rationale: The correct answer is B: Disconnect items before cleaning. This is the safest way to prevent electrical shock as it ensures that no electrical current is flowing through the items being cleaned. Running wires under the carpet (A) can create a tripping hazard and increase the risk of damage to the wires. Grasping the cord when unplugging items (C) can lead to accidental contact with live wires. Using masking tape to secure cords to the floor (D) can damage the cords and increase the risk of tripping. Therefore, disconnecting items before cleaning is the most effective way to prevent electrical shock.
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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. Using a nonvented furnace can lead to carbon monoxide poisoning, posing a significant safety risk. This choice stands out as it directly contradicts safety measures by using a potentially hazardous heating source. Choice A demonstrates awareness of changing carbon monoxide detector batteries timely. Choice B indicates proactivity in chimney maintenance. Choice C shows understanding of seeking help if necessary. Choices E, F, and G are irrelevant. In summary, choice D is the only one that poses a direct safety concern, making it the correct answer.
The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing?
- A. Young infant
- B. Toddler
- C. Preschooler
- D. Adolescent
Correct Answer: B
Rationale: The correct answer is B: Toddler. Toddlers are at highest risk for lead poisoning due to their habit of putting objects in their mouths. Lead exposure can come from old paint, soil, or water. Young infants have less exposure due to limited mobility. Preschoolers are less at risk as they are less likely to engage in mouthing behaviors. Adolescents have lower risk as they are less likely to come into contact with lead sources.
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.
An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient?
- A. Positions patient's buttocks close to the front of wheelchair seat
- B. Backs wheelchair into elevator
- C. leading with large rear wheels first
- D. Places locked wheelchair on same side of bed as patient's weaker side
- E. Unlocks wheelchair for easy maneuverability when patient is transferring
Correct Answer: B
Rationale: The correct answer is B because backing the wheelchair into the elevator allows the nurse to maintain visual contact with the patient and ensures a safe exit from the elevator. This also prevents any potential accidents or injuries that may occur if the wheelchair is pushed forward into the elevator, where the nurse may not be able to see obstacles or other individuals. Positioning the patient's buttocks close to the front of the wheelchair seat (choice A) may cause discomfort and pressure ulcers. Leading with large rear wheels first (choice C) can be dangerous as it may cause the wheelchair to tip over. Placing a locked wheelchair on the same side of the bed as the patient's weaker side (choice D) restricts the patient's ability to access the wheelchair. Unlocking the wheelchair for easy maneuverability (choice E) is important but not directly related to safe transport 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.
Correct Answer: A,B,C,D
Rationale: The correct actions for the nurse to take in this scenario are A, B, C, and D. Closing all doors helps contain the fire and smoke, protecting patients. Noting evacuation routes ensures a quick and safe exit strategy if needed. Identifying oxygen shut-offs prevents potential fuel for a fire. Moving bedridden patients in their bed is crucial for their safety and transportability. Waiting for the fire department (choice E) is not recommended as immediate action by the nurse is necessary to ensure patient safety.