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 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. Carbon monoxide is a colorless, odorless gas that can be deadly if inhaled in high concentrations. The other choices demonstrate good safety practices such as changing batteries on detectors, scheduling chimney inspections, and recognizing symptoms of heater issues. Using a nonvented furnace is the only unsafe practice mentioned, hence requiring immediate follow-up to educate the patient on the dangers of carbon monoxide poisoning.
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.
The nurse enters the patient's room and notices a small fire in the headlight above the bed. In which order will the nurse perform the steps?
- A. Pull the alarm.
- B. Remove the patient.
- C. Use the fire extinguisher.
- D. Close doors and windows.
Correct Answer: A
Rationale: The correct order is A, C, B, D. Pulling the alarm alerts others. Using the fire extinguisher is next to try to extinguish the fire. Removing the patient ensures safety. Closing doors and windows helps contain the fire. Choice A is correct as it prioritizes alerting others to the fire emergency. Choice C is not the first step as the alarm should be pulled before attempting to use the fire extinguisher. Choice B should follow using the fire extinguisher to ensure the patient's safety. Choice D is the last step to prevent the fire from spreading.
A homeless adult patient presents to the emergency department. The nurse obtains the following 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 nurse should address the temperature (Choice B) immediately because it is below the normal range (normal range is around 97-99°F). A low body temperature, such as 94.8°F, can indicate hypothermia, which is a medical emergency requiring prompt intervention to prevent complications like organ dysfunction or cardiac arrest. Addressing the temperature first is crucial to prevent further deterioration of the patient's condition.
Other choices are not as urgent:
A: Respiratory rate (12 breaths per minute) is within the normal range.
C: Apical pulse (58 beats per minute) is slightly lower but not immediately life-threatening.
D: Blood pressure (106/56 mmHg) is on the lower side but not acutely concerning.
When making rounds the nurse observes a purple wristband on a patient's wrist. How will the nurse interpret this finding?
- A. The patient is allergic to certain medications or foods.
- B. The patient has do not resuscitate preferences.
- C. The patient has a high risk for falls.
- D. The patient is at risk for seizures.
Correct Answer: B
Rationale: The correct answer is B: The patient has do not resuscitate preferences. A purple wristband typically signifies that a patient has chosen do not resuscitate (DNR) status. This means that the patient has made a decision to not receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. This information is crucial for healthcare providers to know and respect the patient's wishes. The other choices are incorrect because a purple wristband does not indicate allergies (A), fall risk (C), or seizure risk (D). It is essential for the nurse to be aware of the significance of different colored wristbands to provide appropriate care and respect the patient's autonomy.