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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.
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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 behavior of repeatedly removing the nasogastric tube poses a risk to their safety and health. Restraints may be considered to prevent harm. Refusing to call for help (A) can be addressed through other means. Confusion about time (C) could be due to hospitalization. Difficulty sleeping and requesting items (D) may indicate discomfort but do not necessarily require restraints.
The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?
- A. Are you able to hear the tornado sirens in your area?
- B. Are you able to read your favorite book?
- C. Are you able to taste spices like before?
- D. Are you able to open a jar of pickles?
Correct Answer: A
Rationale: The correct answer is A: "Are you able to hear the tornado sirens in your area?" This is the most important question because hearing loss is a common age-related physiological change that can affect safety, especially during emergencies like tornadoes. The ability to hear warning signals is crucial for timely response and ensuring the safety of older adults. Choices B, C, and D are not as critical for safety concerns compared to the ability to hear warning sirens. Older adults may use aids for reading, cooking, or opening jars, but compromised hearing can directly impact their ability to respond to emergencies effectively.
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.
The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?
- A. Monitor for specific symptoms.
- B. Manage all patients using standard precautions.
- C. Transport patients quickly.
- D. Prepare for post-traumatic stress.
Correct Answer: B
Rationale: The correct answer is B: Manage all patients using standard precautions. This is the priority action because in a potential bioterrorism attack, the safety of healthcare staff and patients is paramount. By implementing standard precautions, the nurse can help prevent the spread of any potential bioterrorism agent to other patients or staff. Monitoring for specific symptoms (choice A) can be important but comes after ensuring safety through infection control. Transporting patients quickly (choice C) may increase exposure risk. Preparing for post-traumatic stress (choice D) is important but not the priority in the immediate response to a potential bioterrorism attack.
The nurse is discussing threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?
- A. Smoking even at parties is not good for my body.
- B. Our campus is safe; we leave our dorms unlocked all the time.
- C. As long as I have only two drinks, I can still be the designated driver.
- D. I am young, so I can work nights and go to school with 2 hours' sleep.
Correct Answer: A
Rationale: The correct answer is A: "Smoking even at parties is not good for my body." This statement indicates an understanding of the threats to adult safety as it acknowledges the harmful effects of smoking on one's health. Smoking increases the risk of various health problems, such as lung cancer and heart disease. By recognizing the negative impact of smoking, the group member shows an understanding of the importance of making healthy choices to ensure their safety and well-being.
Other choices are incorrect:
B: Leaving dorms unlocked poses a safety risk.
C: Even with two drinks, driving impairs judgment and reaction time.
D: Working nights with minimal sleep can lead to fatigue-related accidents.
In summary, choice A is correct as it demonstrates awareness of the health risks associated with smoking, while the other choices overlook potential safety threats.