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 cycling accidents can be severe or fatal. A properly fitting helmet can reduce the risk of head injuries significantly. It is crucial for the nurse to emphasize the importance of wearing a helmet every time a child rides a bike.
The other choices are incorrect because while shin guards, swimming goggles, and sliding shorts are important for specific sports, they do not have the same level of overall impact on safety as a properly fitting bicycle helmet. It is essential to prioritize the safety item that has the most potential to prevent serious injuries, which in this case is the bicycle helmet.
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A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
- A. Determining the need for restraints
- B. Assessing the patient's orientation
- C. Obtaining an order for a restraint
- D. Applying the restraint
Correct Answer: D
Rationale: The correct answer is D: Applying the restraint. The rationale is that nursing assistive personnel can perform tasks that involve direct patient care under the supervision of a nurse. Applying restraints is a task that involves following specific guidelines and does not require critical thinking or decision-making skills. Tasks A, B, and C involve assessing, determining the need, and obtaining orders for restraints, which require nursing judgment and cannot be delegated to nursing assistive personnel. Other choices are left blank as they are not relevant to the question.
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.
For choice D, it is essential to discuss steps to take if the seizure does not stop as it ensures the family is prepared and knows when to seek medical help. This is crucial for the safety of the patient.
For choice E, instructing the family to reorient and reassure the patient after regaining consciousness helps provide emotional support and comfort, promoting a sense of security and reducing anxiety post-seizure.
Choices A, B, and C are incorrect as they involve unsafe practices that can harm the patient. Restraining the patient during a seizure can lead to injury, moving the patient during a seizure can also cause harm, and inserting a tongue depressor is not recommended during a seizure as it can obstruct the airway.
Therefore, choices D and E are the most appropriate interventions for the patient and family in this scenario.
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 higher risk for lead poisoning due to their hand-to-mouth behavior and increased exposure to lead-containing objects. Young infants are less likely to be mobile and interact with potential sources of lead. Preschoolers and adolescents have lower risk compared to toddlers due to reduced mouthing behavior. Therefore, the nurse is most likely assessing a toddler for lead poisoning.
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 important to prevent electrical shock as it ensures that there is no power running through the appliances while they are being cleaned. Running wires under the carpet (A) can lead to overheating and potential fire hazards. Grasping the cord when unplugging items (C) is unsafe as it can cause damage to the cord and increase the risk of electrical shock. Using masking tape to secure cords to the floor (D) is not recommended as it can lead to tripping hazards and damage to the cords.
The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next?
- A. Do nothing, no harm has occurred.
- B. Notify the health care provider.
- C. Complete an incident report.
- D. Assess the patient.
Correct Answer: B
Rationale: The correct answer is B: Notify the health care provider. After assessing the patient and placing them back in bed, the nurse should inform the healthcare provider about the incident to ensure proper evaluation and follow-up care. This step is crucial in addressing any potential underlying issues that may have led to the fall and preventing future falls. Notifying the healthcare provider also ensures that the patient's safety and well-being are prioritized.
Choice A (Do nothing) is incorrect because the patient falling out of bed is a significant incident that requires further action. Choice C (Complete an incident report) is not the immediate next step as notifying the healthcare provider takes precedence. Choice D (Assess the patient) has already been done, so it is not the next necessary action.