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A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident?
- A. Pathogenic asepsis
- B. Medical asepsis
- C. Surgical asepsis
- D. Clean asepsis
Correct Answer: C
Rationale: The correct answer is C: Surgical asepsis. This technique involves creating and maintaining a sterile field to prevent contamination during invasive procedures like catheter insertion. The nurse will use sterile gloves, drapes, and equipment to minimize the risk of infection. Pathogenic asepsis (A) focuses on removing or destroying pathogens but may not ensure sterility. Medical asepsis (B) aims to reduce the number of pathogens but does not achieve a sterile environment. Clean asepsis (D) involves cleanliness but not the level of sterility required for invasive procedures.
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The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. Which priority concern will require collaboration with social services?
- A. The electricity was turned off 3 days ago.
- B. The water comes from the county water supply.
- C. A son and family recently moved into the home.
- D. This home is not furnished with a microwave oven.
Correct Answer: A
Rationale: The correct answer is A because the lack of electricity poses a serious risk to the patient's health and safety, affecting the ability to store and prepare food properly, maintain a comfortable temperature, and access medical devices if needed. Collaboration with social services is crucial to address this urgent issue. Choices B, C, and D do not directly impact the patient's immediate health needs and can be addressed at a later time.
The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring?
- A. Tile floors, cold food, scratchy linen, and noisy alarms.
- B. Dirty floors, hallways blocked, medication room locked, and alarms set.
- C. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach.
- D. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly.
Correct Answer: D
Rationale: The correct answer is D because wet floors unmarked pose slip hazards, patient pinching fingers in the door indicates lack of safety measures, failure to use a lift for patient increases risk of injury, and alarms not functioning properly can lead to delayed response. Choice A includes minor inconveniences but not significant safety risks. Choice B focuses on facility maintenance rather than direct patient safety risks. Choice C mentions minor issues like empty ice machine and unlocked supply cabinet that do not directly impact patient safety.
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. D is important as it addresses the need for the family to know what to do if the seizure does not stop, such as calling emergency services. E is crucial as it focuses on the post-seizure care, which includes reorienting and reassuring the patient. A is incorrect as restraining a patient during a seizure can be harmful. B is incorrect as moving the patient during a seizure can lead to injury. C is incorrect as inserting a tongue depressor can also be harmful and is not recommended during a seizure.
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 trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working?
- A. The patient continues to get up from the chair at the nurses' station.
- B. The patient gets restless when the sitter leaves for lunch.
- C. The patient folds three washcloths over and over.
- D. The patient apologizes for being 'such a bother.'
Correct Answer: C
Rationale: The correct answer is C because the patient folding three washcloths over and over demonstrates engagement in a repetitive, soothing activity, indicating reduced agitation or restlessness. Choice A shows lack of improvement as the patient is still trying to get up. Choice B suggests dependency on the sitter for comfort. Choice D indicates compliance due to guilt, not necessarily effectiveness of the alternative.