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A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?
- A. Identifies patient with one identifier before transporting to x-ray department
- B. Initiates an intravenous (IV) catheter using clean technique on the first try
- C. Uses medication bar coding when administering medications
- D. Obtains vital signs to place on a surgical patient's chart
Correct Answer: C
Rationale: The correct answer is C because using medication bar coding ensures the right medication is given to the right patient at the right time, aligning with National Patient Safety Goals to prevent medication errors. This process enhances patient safety by verifying the medication through scanning before administration.
Choice A may be a good practice, but it does not directly relate to a specific patient safety goal. Choice B focuses on IV catheter insertion technique, which is important but not specifically related to patient safety goals. Choice D is important for patient care but doesn't directly address medication safety.
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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.
A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.)
- A. Smoking in bed helps me relax and fall asleep.
- B. We never leave candles burning when we are gone.
- C. We use the same space heater my grandparents used.
- D. We use the RACE method when using the fire extinguisher.
- E. There is a fire extinguisher in the kitchen and garage workshop.
Correct Answer: A,C,D
Rationale: Correct Answer: A, C, D
Rationale:
A: Smoking in bed is a significant fire hazard as it can lead to accidental fires if the individual falls asleep without extinguishing the cigarette. Intervening is crucial to prevent potential disasters.
C: Using an old space heater may pose a safety risk due to outdated technology and potential malfunctions, making it unsafe to use. Intervening is necessary to ensure the safety of the family.
D: Using the RACE method (Rescue, Alarm, Contain, Extinguish) during a fire emergency is important for effective response. Confirming that the family is aware of this method ensures proper handling of fire situations.
Summary:
B: Leaving candles burning unsupervised is a safety concern, but the family's practice of not doing so mitigates the risk.
E: Having fire extinguishers in accessible locations is a good practice for fire safety, indicating preparedness and prevention.
Overall, choices A, C, and D require
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 electricity being turned off poses a significant risk to the older-adult patient's health and safety. Lack of electricity can lead to spoiled food, inability to cook or store food properly, and compromised medical equipment like refrigerated medications. Collaboration with social services is necessary to address this immediate concern. Choices B, C, and D are less critical as county water supply is generally safe, a son moving in is not directly related to the patient's condition, and lack of a microwave oven is not as urgent as lack of electricity in this situation.
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 notify the healthcare provider to ensure appropriate evaluation and management of the patient's fall. This is important for patient safety and to prevent any potential complications or underlying issues that may have contributed to the fall. Notifying the healthcare provider promptly allows for further assessment, interventions, and necessary precautions to be implemented.
Other choices are incorrect:
A: Doing nothing is not appropriate as the patient has experienced a fall, which requires further evaluation.
C: Completing an incident report is important, but notifying the healthcare provider takes precedence to ensure immediate appropriate care.
D: Assessing the patient has already been done, so the next step is to involve the healthcare provider for further management.
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.