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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 answer includes choices B, D, and E. Choice B ensures that the type and location of the restraint are clearly specified, promoting safe and appropriate use. Choice D mandates a face-to-face assessment by the healthcare provider before ordering restraints, ensuring that the decision is based on a thorough evaluation of the patient's condition. Choice E is crucial as it requires the healthcare provider to specify the duration and circumstances of restraint use, helping prevent unnecessary or prolonged use. Choices A, C, F, and G are incorrect because relying on PRN orders (A) may lead to inconsistent and potentially unsafe application of restraints, renewing orders every 24 hours (C) may not adequately address the patient's changing needs, and the absence of specific details in choices F and G can result in ambiguity and misuse of restraints.
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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 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: Correct Answer: B
Rationale: A surgical sponge left in the patient's incision is a Never Event as it is a preventable medical error that should never occur. The nurse must report this immediately for prompt removal to prevent complications like infection or obstruction. This event breaches patient safety protocols and can lead to serious harm or even death.
Summary of other choices:
A: No blood incompatibility is a positive finding indicating patient safety measures were correctly followed.
C: Pulmonary embolism can occur despite proper precautions and is not always preventable.
D: Stage II pressure ulcer, while concerning, may not necessarily be a Never Event as it can be a result of various factors and is not always preventable with current medical knowledge.
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 important to prevent electrical shock as it ensures that there is no power running through the appliances while they are being cleaned. Running wires under the carpet (A) can lead to overheating and potential fire hazards. Grasping the cord when unplugging items (C) is unsafe as it can cause damage to the cord and increase the risk of electrical shock. Using masking tape to secure cords to the floor (D) is not recommended as it can lead to tripping hazards and damage to the cords.
A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session?
- A. Proper fit of a bicycle helmet
- B. Proper fit of soccer shin guards
- C. Proper fit of swimming goggles
- D. Proper fit of baseball sliding shorts
Correct Answer: A
Rationale: The correct answer is A: Proper fit of a bicycle helmet. This is the most important safety item to include because head injuries from cycling accidents can be severe or fatal. A properly fitting helmet can reduce the risk of head injuries significantly. It is crucial for the nurse to emphasize the importance of wearing a helmet every time a child rides a bike.
The other choices are incorrect because while shin guards, swimming goggles, and sliding shorts are important for specific sports, they do not have the same level of overall impact on safety as a properly fitting bicycle helmet. It is essential to prioritize the safety item that has the most potential to prevent serious injuries, which in this case is the bicycle helmet.
The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.)
- A. Where did you fall?
- B. What time did the fall occur?
- C. What were you doing when you fell?
- D. What types of injuries occurred after the fall?
- E. Did you obtain an electronic safety alert device after the fall?
- F. What are your medical problems that may have caused the fall?
Correct Answer: A, B, C, D
Rationale: The correct answers are A, B, C, and D. The SPLATT acronym stands for Symptoms, Previous falls, Location, Activity, Time, and Trauma. Therefore, the nurse should ask where the fall happened (A), what the patient was doing when they fell (C), and what types of injuries occurred after the fall (D) to assess the circumstances surrounding the fall. Asking about the time of the fall (B) helps determine if there are any time-related factors contributing to the fall. These questions provide crucial information for assessing the patient's risk factors and potential interventions. Choices E and F are incorrect because they do not directly pertain to the SPLATT components and may not provide as relevant information for assessing the fall risk in this situation.