Nokea
A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.)
- A. Health care provider orders restraints prn (as needed).
- B. Health care provider writes the type and location of the restraint.
- C. Health care provider renews orders for restraints every 24 hours.
- D. Health care provider performs a face-to-face assessment prior to the order.
- E. Health care provider specifies the duration and circumstances under which the restraint will be used.
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. Choice B ensures the type and location of the restraint are specified, promoting safe application. Choice D, the face-to-face assessment, is crucial to assess the need for restraints. Choice E, specifying duration and circumstances, ensures restraints are used only when necessary. Choice A is incorrect as PRN orders can lead to inappropriate use. Choice C is incorrect as orders should be renewed every 2 hours, not 24.
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A patient has an ankle restraint applied. Upon assessment
- A. the nurse finds the toes a light blue color. Which action will the nurse take next?
- B. Remove the restraint.
- C. Place a blanket over the feet.
- D. Do a complete head-to-toe neurologic assessment.
- E. Take the patient's vital signs.
Correct Answer: A
Rationale: The correct answer is A because a light blue color in the toes indicates poor circulation due to the restraint. The nurse should assess for tissue damage and remove the restraint immediately to restore circulation. Removing the restraint is the priority to prevent further complications. Choice B is incorrect as it doesn't address the circulatory issue. Choices C, D, and E are not the immediate concern and can be addressed after addressing the circulation problem.
During the admission assessment
- A. the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
- B. The patient is oriented.
- C. The patient takes a hypnotic.
- D. The patient walks 2 miles a day.
- E. The patient recently became widowed.
Correct Answer: B
Rationale: The correct answer is B because orientation indicates the patient's awareness of self, time, and place, affecting their safety awareness. A high level of orientation reduces fall risk as the patient can navigate their environment effectively. Other choices are incorrect as assessing fall risk (A) is important but doesn't directly indicate increased risk, taking a hypnotic (C) may increase fall risk but isn't the most direct indicator, walking 2 miles a day (D) is a positive sign of physical health, and being widowed (E) may impact mental health but doesn't directly relate to fall risk.
A homeless adult patient presents to the emergency department with vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
- A. Respiratory rate
- B. Temperature
- C. Apical pulse
- D. Blood pressure
Correct Answer: B
Rationale: The correct answer is B: Temperature. A temperature of 94.8°F indicates hypothermia, which can be life-threatening and requires immediate attention to prevent further complications. Hypothermia can lead to decreased heart rate and blood pressure, affecting overall perfusion. Addressing the temperature first is crucial to prevent further deterioration. The other vital signs are within normal range and may not pose an immediate threat to the patient's life.
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 monitoring for Never Events. Which finding indicates the nurse will report a Never Event?
- A. No blood incompatibility occurs with a blood transfusion.
- B. A surgical sponge is left in the patient's incision.
- C. Pulmonary embolism after lung surgery.
- D. Stage II pressure ulcer.
Correct Answer: B
Rationale: The correct answer is B because leaving a surgical sponge in a patient's incision is a Never Event - a preventable medical error that should never occur. Reporting this event is crucial for patient safety and quality care. Choices A, C, and D are not Never Events as they can occur despite adherence to best practices and guidelines. Choice A indicates a successful blood transfusion without complications, C is a known risk after lung surgery, and D can develop even with proper preventive measures.