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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.
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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.
The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.)
- A. Water outdoor plants with a nozzle and hose.
- B. Walk to the mailbox in the summer.
- C. Encourage yearly eye examinations.
- D. Use bathtubs without safety strips.
- E. Keep pathways clutter free.
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
- B: Walking to the mailbox in the summer promotes physical activity and maintains strength and balance, reducing fall risk.
- C: Yearly eye examinations help detect vision problems that can increase fall risk.
- E: Keeping pathways clutter-free prevents tripping hazards, reducing the risk of falls.
Other choices are incorrect:
- A: Watering outdoor plants with a nozzle and hose does not directly impact fall prevention.
- D: Using bathtubs without safety strips increases the risk of slipping and falling.
- F, G: No additional choices provided.
The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?
- A. Impaired home maintenance
- B. Deficient knowledge
- C. Risk for poisoning
- D. Risk for injury
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. The patient's confusion and behavior of trying to get out of bed and pulling at the IV tubing indicate a potential risk for self-injury. Confusion can lead to falls or accidents, and pulling at the IV tubing can cause dislodgement leading to infection or inadequate medication delivery. The nurse's priority is to prevent harm to the patient.
Other choices are incorrect because:
A: Impaired home maintenance focuses on the patient's ability to maintain a safe and healthy home environment, not applicable in this acute care setting.
B: Deficient knowledge pertains to lack of understanding about a health condition or treatment, not relevant to the immediate safety concern.
C: Risk for poisoning does not align with the current scenario of potential physical harm due to the patient's confused behavior.
The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.)
- A. Water outdoor plants with a nozzle and hose.
- B. Walk to the mailbox in the summer.
- C. Encourage yearly eye examinations.
- D. Use bathtubs without safety strips.
- E. Keep pathways clutter free.
Correct Answer: B, C, E
Rationale: Correct Answer: B, C, E
Rationale:
- B: Walking regularly helps maintain strength and balance, reducing fall risk.
- C: Yearly eye exams can detect vision problems that contribute to falls.
- E: Clear pathways prevent tripping hazards, reducing the risk of falls.
Incorrect Choices:
- A: Watering plants is unrelated to fall prevention.
- D: Bathtubs without safety strips increase fall risk.
- F, G: No additional choices given.
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.