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A homeless adult patient presents to the emergency department with vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
- A. Respiratory rate
- B. Temperature
- C. Apical pulse
- D. Blood pressure
Correct Answer: B
Rationale: The correct answer is B: Temperature. A temperature of 94.8°F indicates hypothermia, which can be life-threatening and requires immediate attention to prevent further complications. Hypothermia can lead to decreased heart rate and blood pressure, affecting overall perfusion. Addressing the temperature first is crucial to prevent further deterioration. The other vital signs are within normal range and may not pose an immediate threat to the patient's life.
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A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session?
- A. Proper fit of a bicycle helmet.
- B. Proper fit of soccer shin guards.
- C. Proper fit of swimming goggles.
- D. Proper fit of baseball sliding shorts.
Correct Answer: A
Rationale: The correct answer is A: Proper fit of a bicycle helmet. This is the most important safety item to include because head injuries from bicycle accidents can be life-threatening. Properly fitting helmets can significantly reduce the risk of head injuries. Soccer shin guards, swimming goggles, and baseball sliding shorts are important for their respective activities, but they do not have the same potential life-saving impact as a bicycle helmet. It is crucial for the nurse to emphasize the importance of wearing a properly fitting helmet to prevent head injuries during biking.
The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event?
- A. No blood incompatibility occurs with a blood transfusion.
- B. A surgical sponge is left in the patient's incision.
- C. Pulmonary embolism after lung surgery.
- D. Stage II pressure ulcer.
Correct Answer: B
Rationale: The correct answer is B because leaving a surgical sponge in a patient's incision is a Never Event - a preventable medical error that should never occur. Reporting this event is crucial for patient safety and quality care. Choices A, C, and D are not Never Events as they can occur despite adherence to best practices and guidelines. Choice A indicates a successful blood transfusion without complications, C is a known risk after lung surgery, and D can develop even with proper preventive measures.
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.
A confused patient is restless and continues to remove oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention?
- A. Risk for injury: Check on patient every 15 minutes.
- B. Risk for suffocation: Place “Oxygen in Use†sign.
- C. Disturbed body image: Encourage patient expression.
- D. Deficient knowledge: Explain oxygen therapy.
Correct Answer: A
Rationale: The correct answer is A: Risk for injury: Check on patient every 15 minutes. This is the priority nursing diagnosis because the patient is at risk for harm due to removing essential medical equipment. Continuous monitoring can prevent potential injuries. Choice B is incorrect as simply placing a sign does not actively address the patient's behavior. Choice C is incorrect as the patient's actions are not related to body image. Choice D is incorrect as the patient's behavior is not due to a lack of knowledge about oxygen therapy. Monitoring the patient closely is crucial in ensuring their safety and preventing harm in this situation.
The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action?
- A. The patient removes the armband to bathe.
- B. The patient wears the red nonslip footwear.
- C. The patient insists on taking a “water†pill in the evening.
- D. The patient who is allergic to penicillin asks the name of a new medicine.
Correct Answer: B
Rationale: The correct answer is B. The patient wearing the red nonslip footwear indicates an understanding of the yellow armband. This is because the yellow armband typically signifies fall risk, and wearing red nonslip footwear is a safety measure to prevent falls. The other choices are incorrect because they do not directly relate to the significance of the yellow armband. Choice A focuses on bathing, choice C on medication timing, and choice D on medication allergies, which are not directly related to fall risk.