Nokea
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.
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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 is commonly used in healthcare settings to indicate that a patient has expressed their wish to not be resuscitated in case of cardiac arrest or other life-threatening situations. This information is crucial for healthcare providers to respect the patient's autonomy and ensure their wishes are honored.
Incorrect choices:
A: Allergies are typically indicated by a different color wristband, such as red.
C: High fall risk is usually denoted by a different color wristband, such as yellow.
D: Seizure risk is often indicated by a different color wristband, such as orange.
The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take?
- A. Assess the patient.
- B. Gather restraint supplies.
- C. Try alternatives to restraint.
- D. Call the health care provider for a restraint order.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient. The priority action is to assess the patient to determine the underlying cause of the sudden confusion and agitation. This will help the nurse identify any medical issues or discomfort causing the behavior, such as hypoxia, infection, or medication side effects. By assessing the patient first, the nurse can address the root cause of the behavior and implement appropriate interventions, which may include addressing the patient's needs, providing comfort measures, or involving other healthcare team members as needed. Gathering restraint supplies (B) should not be the initial action as it does not address the underlying cause of the behavior. Trying alternatives to restraint (C) is important but should come after assessing the patient. Calling the healthcare provider for a restraint order (D) should only be considered after other interventions have been attempted.
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.
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 in preventing the transmission of pathogens because hands are a common mode of pathogen spread. Washing hands effectively removes pathogens and reduces the risk of infection. Choice B (Wash wound) is important for wound care but not as effective in preventing transmission of pathogens. Choice C (Wear gloves) is important for personal protection but does not address the primary mode of transmission. Choice D (Wear eye protection) is not directly related to preventing transmission through hand hygiene. It is essential to prioritize hand hygiene as the most effective method of preventing the spread 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.