Nokea
Which patient will the nurse see first?
- A. A 56-year-old patient with oxygen with a lighter on the bedside table
- B. A 56-year-old patient with oxygen using an electric razor for grooming
- C. A 1-month-old infant looking at a shiny
- D. round battery just out of arm's reach
- E. A 1-month-old infant with a pacifier that has no string around the baby's neck
Correct Answer: B
Rationale: The correct answer is B because using an electric razor near oxygen can lead to a fire hazard due to sparks. Oxygen supports combustion. Oxygen and electric razors should not be used together to prevent fires. Choices A, C, D, and E do not pose immediate safety risks requiring urgent attention. Choice A may be a safety concern but is less urgent compared to choice B. The infant in choice E is safe as there is no string around the pacifier. The infant in choice C is not in immediate danger from looking at a shiny battery. The battery in choice D is out of reach, so the infant is not at immediate risk.
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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.
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 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.
The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.)
- A. One family member has gone to lunch.
- B. Patient is placed in bilateral wrist restraints at 0815.
- C. Bilateral radial pulses present, 2+, hands warm to touch.
- D. Straps with quick-release buckle attached to bed side rails.
- E. Attempts to distract the patient with television are unsuccessful.
Correct Answer: B,C,E,F
Rationale: Correct Answer: B, C, E, F
Rationale:
B: Documenting the specific time and type of restraints applied ensures accurate monitoring and compliance with protocols.
C: Noting the presence and quality of radial pulses helps in assessing circulation and preventing complications related to restraints.
E: Documenting unsuccessful attempts to distract the patient with television indicates efforts made to address the patient's needs.
F: Recording any interventions or actions taken is crucial for continuity of care and legal documentation.
Summary:
A: Irrelevant to the patient's care in restraints.
D: Focuses on the equipment used rather than patient assessment.
G: No information provided to evaluate this option.
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.