Nokea
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 puts the patient at risk for falls due to sudden drops in blood pressure when changing positions. Orthostatic hypotension can lead to dizziness, lightheadedness, and potential falls. A: Age alone does not necessarily indicate fall risk. B: Having 20/20 vision is not directly related to fall risk. C: Urinary continence does not directly indicate fall risk. Therefore, the correct choice is D as it directly correlates with an increased risk of falls.
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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 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.
A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?
- A. Identifies patient with one identifier before transport
- B. Initiates IV catheter using clean technique
- C. Uses medication bar coding
- D. Obtains vital signs for surgical chart
Correct Answer: C
Rationale: The correct answer is C: Uses medication bar coding. This action aligns with the National Patient Safety Goals by helping to ensure accurate medication administration through technology. Bar coding reduces the risk of medication errors by verifying the right patient, medication, dose, route, and time. Option A is important but does not specifically align with the National Patient Safety Goals. Option B mentions clean technique, but sterile technique is required for IV catheter insertion. Option D is important for surgical preparation but does not directly relate to patient safety goals.
A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?
- A. Remove the restraint.
- B. Place a blanket over the feet.
- C. Immediately do a complete head-to-toe neurologic assessment.
- D. Take the patient's blood pressure pulse temperature and respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Remove the restraint. The blue color in the toes indicates impaired circulation, possibly due to the ankle restraint being too tight. Removing the restraint will allow blood flow to return to the toes and prevent further complications such as tissue damage or necrosis. Choice B is incorrect as it does not address the underlying circulation issue. Choice C is not necessary unless there are other concerning neurological symptoms present. Choice D is important for overall assessment but does not address the immediate issue of impaired circulation.
The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working?
- A. The patient continues to get up from the chair at the nurses' station.
- B. The patient gets restless when the sitter leaves for lunch.
- C. The patient folds three washcloths over and over.
- D. The patient apologizes for being 'such a bother.'
Correct Answer: C
Rationale: The correct answer is C because the patient folding three washcloths over and over indicates engagement in a task, showing decreased restlessness or agitation. This behavior suggests the patient is able to focus on a repetitive and soothing activity, indicating successful use of alternatives to restraint. Choice A shows continued restlessness, choice B demonstrates dependence on the sitter, and choice D indicates the patient's emotional response, none of which directly reflect the effectiveness of the alternative intervention.
A home health nurse is assessing a family's home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up?
- A. Plastic grocery bags are neatly stored under the counter.
- B. Electric outlets are covered in all rooms.
- C. No bumper pads are in the crib.
- D. Crib slats are 5 cm apart.
Correct Answer: A
Rationale: The correct answer is A because storing plastic grocery bags under the counter poses a suffocation risk to the toddler. Toddlers could access the bags and potentially suffocate if they put a bag over their head. This finding requires immediate follow-up to ensure the safety of the child.
Choice B is incorrect because covering electric outlets is a safety measure for toddlers, not a cause for follow-up. Choice C is also incorrect because not having bumper pads in the crib is actually recommended for safe sleep practices. Choice D is incorrect as well since crib slats being 5 cm apart is within the safety guidelines.