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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: Keep the patient on fall risk until discharge. This is because fall precautions should be maintained throughout the patient's stay to ensure their safety. Checking on the patient once a shift (A) may not be sufficient to prevent falls. Encouraging visitors in the early evening (B) could distract the patient and increase fall risk. Placing all four side rails in the 'up' position (C) can lead to entrapment or injury. Therefore, the best practice is to keep the patient on fall risk until discharge to maintain a high level of vigilance and prevent falls effectively.
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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C: Using an old space heater may pose a safety risk due to outdated technology and potential malfunctions, making it unsafe to use.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 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.
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 patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?
- A. Impaired home maintenance
- B. Deficient knowledge
- C. Risk for poisoning
- D. Risk for injury
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. The patient's confusion and behavior of trying to get out of bed and pulling at the IV tubing indicate a potential risk for self-injury. Confusion can lead to falls or accidents, and pulling at the IV tubing can cause dislodgement leading to infection or inadequate medication delivery. The nurse's priority is to prevent harm to the patient.
Other choices are incorrect because:
A: Impaired home maintenance focuses on the patient's ability to maintain a safe and healthy home environment, not applicable in this acute care setting.
B: Deficient knowledge pertains to lack of understanding about a health condition or treatment, not relevant to the immediate safety concern.
C: Risk for poisoning does not align with the current scenario of potential physical harm due to the patient's confused behavior.
The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint?
- A. The patient refuses to call for help to go to the bathroom.
- B. The patient continues to remove the nasogastric tube.
- C. The patient gets confused regarding the time at night.
- D. The patient does not sleep and continues to ask for items.
Correct Answer: B
Rationale: The correct answer is B because the patient's action of repeatedly removing the nasogastric tube poses a direct risk to their health and safety. This behavior indicates a lack of understanding or ability to comprehend the importance of the tube in their care. Restraints may be necessary to prevent harm in this situation. Refusing to call for help, confusion about time, and insomnia do not directly indicate a need for restraints. These behaviors may require further assessment and interventions, but they do not pose an immediate threat to the patient's well-being like removing a necessary medical device.