Nokea
A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?
- A. 55 years old
- B. 20/20 vision
- C. Urinary continence
- D. Orthostatic hypotension
Correct Answer: D
Rationale: The correct answer is D: Orthostatic hypotension. This finding indicates a drop in blood pressure upon standing, which can lead to dizziness and falls. A 55-year-old age (choice A) does not inherently indicate fall risk. 20/20 vision (choice B) does not directly correlate with fall risk. Urinary continence (choice C) is not a significant fall risk factor. The presence of orthostatic hypotension (choice D) is a clear indicator of potential falls due to the risk of dizziness and loss of balance.
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The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?
- A. Are you able to hear the tornado sirens in your area?
- B. Are you able to read your favorite book?
- C. Are you able to taste spices like before?
- D. Are you able to open a jar of pickles?
Correct Answer: A
Rationale: The correct answer is A: "Are you able to hear the tornado sirens in your area?" This question is most important as hearing loss is a common age-related physiological change that can affect safety during emergencies. Tornado sirens are crucial for alerting individuals to seek shelter.
Summary of other choices:
B: Reading ability is important but not directly related to safety.
C: Taste changes are common with age but do not impact safety significantly.
D: Difficulty opening jars may occur with age but is not as critical for safety in emergencies.
In this context, asking about hearing the tornado sirens is the most relevant question for ensuring the safety of older adults in an assisted-living facility.
The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?
- A. 60° to 64° F
- B. 65° to 75° F
- C. 15° to 17° C
- D. 25° to 28° C
Correct Answer: B
Rationale: The correct answer is B (65° to 75° F) because this temperature range is generally considered comfortable for most individuals, including those with respiratory illnesses experiencing shortness of breath. This range provides a balance between being not too cold to trigger discomfort or exacerbate respiratory symptoms and not too warm to cause overheating or breathing difficulties.
Choice A (60° to 64° F) is too cold and may worsen the patient's shortness of breath by causing them to shiver or feel uncomfortable. Choice C (15° to 17° C) is also too cold and may lead to discomfort and potential respiratory distress. Choice D (25° to 28° C) is too warm and can lead to overheating, exacerbating respiratory symptoms and making breathing more difficult.
The patient is confused
- A. trying to get out of bed
- B. and pulling at the IV tubing. Which nursing diagnosis will the nurse add to the care plan?
- C. Impaired home maintenance
- D. Deficient knowledge
- E. Risk for poisoning
- F. Risk for injury
Correct Answer: D
Rationale: The correct answer is D: Deficient knowledge. The patient's confusion and behavior suggest a lack of understanding regarding the importance of staying in bed and not pulling at the IV tubing. By selecting this nursing diagnosis, the nurse can address the patient's cognitive deficits and provide education to prevent potential harm. Choice A is incorrect as it describes a behavior related to confusion, not a nursing diagnosis. Choice B focuses on the patient's actions rather than the underlying issue of knowledge deficit. Choices C, E, and F are not directly related to the patient's confusion and do not address the root cause of the behavior.
The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?
- A. Increased aggressiveness and blood spots on clothing may indicate substance abuse.
- B. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing.
- C. Adolescents need information about the effects of uncoordination on accidents.
- D. Adolescents need to be reminded to use seat belts primarily on long trips.
Correct Answer: A
Rationale: The correct answer is A because increased aggressiveness and blood spots on clothing are potential signs of substance abuse in adolescents. Aggressiveness and physical changes can indicate underlying issues like substance abuse, which is crucial for parents to recognize for intervention. B is incorrect because aggressiveness alone is not a definitive clue for substance abuse. C is incorrect as it focuses on uncoordination rather than specific signs of substance abuse. D is incorrect as it is a general safety reminder and not specific to substance abuse indicators.
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.