Nokea
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 action of repeatedly removing the nasogastric tube poses a direct risk to their health and safety. This behavior indicates a lack of understanding or ability to comprehend the importance of the tube in their care. Restraints may be necessary to prevent harm in this situation. Refusing to call for help, confusion about time, and insomnia do not directly indicate a need for restraints. These behaviors may require further assessment and interventions, but they do not pose an immediate threat to the patient's well-being like removing a necessary medical device.
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A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?
- A. Wash hands
- B. Wash wound
- C. Wear gloves
- D. Wear eye protection
Correct Answer: A
Rationale: The correct answer is A: Wash hands. This technique is crucial to prevent transmission of pathogens as hands are the most common mode of transmission. Washing hands effectively removes microorganisms, reducing the risk of infection. The other choices are incorrect because washing the wound only addresses local hygiene, wearing gloves and eye protection are important but secondary to hand hygiene in preventing transmission of pathogens.
The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?
- A. 60° to 64° F
- B. 65° to 75° F
- C. 15° to 17° C
- D. 25° to 28° C
Correct Answer: B
Rationale: The correct answer is B: 65° to 75° F. This temperature range is ideal for a patient experiencing respiratory distress as it helps maintain a comfortable environment without being too cold or too warm. Lower temperatures (choice A) can exacerbate breathing difficulties, while the temperature range in Celsius (choice C) is too low for comfort. The temperature range in choice D is too warm and may cause discomfort for the patient. It is important to maintain a moderate temperature to assist the patient in breathing comfortably.
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 nurse is performing the 'Timed Get Up and Go (TUG)' assessment. Which actions will the nurse take? (Select all that apply.)
- A. Ranks a patient as high risk for falls after patient takes 18 seconds to complete.
- B. Teaches patient to rise from a straight back chair using arms for support.
- C. Instructs the patient to walk 10 feet as quickly and safely as possible.
- D. Observes for unsteadiness in patient's gait.
- E. Begins counting after the instructions.
Correct Answer: C,D,F
Rationale: The correct answers are C, D, and F.
C: Instructing the patient to walk 10 feet quickly and safely is a key component of the TUG test to assess mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is important to evaluate balance and stability during the test.
F: Beginning counting after giving instructions ensures an accurate timing of the patient's performance.
Incorrect choices:
A: Ranking a patient as high risk for falls after taking 18 seconds is not accurate as the cutoff time for increased fall risk is typically 12-14 seconds.
B: Teaching the patient to rise from a straight back chair using arms for support is not part of the TUG assessment and may not provide accurate information about the patient's mobility and fall risk.
A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?
- A. Risk for injury: Check on patient every 15 minutes.
- B. Risk for suffocation: Place 'Oxygen in Use' sign on door.
- C. Disturbed body image: Encourage patient to express concerns about body.
- D. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.
Correct Answer: A
Rationale: The correct answer is A: Risk for injury: Check on patient every 15 minutes.
Rationale:
1. Priority: Safety of the patient is the top priority, as the patient is at risk for injury due to attempts to remove essential medical devices.
2. Regular monitoring: Checking on the patient every 15 minutes allows for timely intervention if the patient attempts to remove the oxygen cannula or urinary catheter.
3. Prevention of harm: By checking frequently, nurses can prevent potential harm such as hypoxia or catheter-related complications.
4. Immediate action: This intervention addresses the immediate safety concern and ensures the patient's well-being.
Incorrect choices:
B: Risk for suffocation: Placing a sign does not directly address the patient's behavior.
C: Disturbed body image: Patient's behavior is not related to body image concerns.
D: Deficient knowledge: Explaining the purpose does not address the immediate safety risk.