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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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A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?
- A. Every December is the time to change batteries on the carbon monoxide detector.
- B. I will schedule an appointment with a chimney inspector next week.
- C. If I feel dizzy when using the heater, I need to have it inspected.
- D. When it is cold outside in the winter, I will use a nonvented furnace.
Correct Answer: D
Rationale: The correct answer is D because using a nonvented furnace can lead to carbon monoxide poisoning, which is a significant safety hazard. The nurse should follow up to educate the patient on the dangers of using a nonvented furnace and recommend safer heating alternatives. Choice A is correct as it emphasizes the importance of changing carbon monoxide detector batteries annually. Choice B is correct as scheduling a chimney inspection is a proactive safety measure. Choice C is correct as feeling dizzy while using a heater can indicate a potential issue. Choices E, F, and G are not applicable in this context.
The nurse is discussing threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?
- A. Smoking even at parties is not good for my body.
- B. Our campus is safe; we leave our dorms unlocked all the time.
- C. As long as I have only two drinks, I can still be the designated driver.
- D. I am young, so I can work nights and go to school with 2 hours' sleep.
Correct Answer: A
Rationale: The correct answer is A: "Smoking even at parties is not good for my body." This statement indicates an understanding of the threats to adult safety as it acknowledges the harmful effects of smoking on one's health. Smoking increases the risk of various health problems, such as lung cancer and heart disease. By recognizing the negative impact of smoking, the group member shows an understanding of the importance of making healthy choices to ensure their safety and well-being.
Other choices are incorrect:
B: Leaving dorms unlocked poses a safety risk.
C: Even with two drinks, driving impairs judgment and reaction time.
D: Working nights with minimal sleep can lead to fatigue-related accidents.
In summary, choice A is correct as it demonstrates awareness of the health risks associated with smoking, while the other choices overlook potential safety threats.
A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?
- A. Check on the patient once a shift.
- B. Encourage visitors in the early evening.
- C. Place all four side rails in the 'up' position.
- D. Keep the patient on fall risk until discharge.
Correct Answer: D
Rationale: The correct answer is D because keeping the patient on fall risk until discharge ensures continuous monitoring and implementation of fall precautions. Checking on the patient once a shift (Option A) is not enough for a high fall risk patient. Encouraging visitors in the early evening (Option B) may distract the patient and increase the risk of falls. Placing all four side rails in the 'up' position (Option C) can lead to entrapment and is not recommended. Keeping the patient on fall risk until discharge (Option D) ensures consistent vigilance and preventive measures.
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. During urinary catheter insertion, surgical asepsis is crucial to prevent infection and other procedure-related accidents. Surgical asepsis involves using sterile techniques to minimize the risk of introducing pathogens. The nurse will follow strict protocols such as wearing sterile gloves, using sterile equipment, and maintaining a sterile field. This technique ensures that the urinary catheter is inserted in a sterile environment, reducing the risk of infection. Pathogenic asepsis (A) focuses on destroying pathogens, not preventing their entry during a procedure. Medical asepsis (B) aims to reduce the number of pathogens but does not provide the level of sterility needed for urinary catheter insertion. Clean asepsis (D) involves cleanliness but does not meet the sterile requirements of urinary catheter insertion.
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.