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The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next?
- A. Do nothing, no harm has occurred.
- B. Notify the health care provider.
- C. Complete an incident report.
- D. Assess the patient.
Correct Answer: B
Rationale: The correct answer is B: Notify the health care provider. After assessing the patient and placing them back in bed, the nurse should notify the healthcare provider to ensure appropriate evaluation and management of the patient's fall. This is important for patient safety and to prevent any potential complications or underlying issues that may have contributed to the fall. Notifying the healthcare provider promptly allows for further assessment, interventions, and necessary precautions to be implemented.
Other choices are incorrect:
A: Doing nothing is not appropriate as the patient has experienced a fall, which requires further evaluation.
C: Completing an incident report is important, but notifying the healthcare provider takes precedence to ensure immediate appropriate care.
D: Assessing the patient has already been done, so the next step is to involve the healthcare provider for further management.
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A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session?
- A. Proper fit of a bicycle helmet
- B. Proper fit of soccer shin guards
- C. Proper fit of swimming goggles
- D. Proper fit of baseball sliding shorts
Correct Answer: A
Rationale: The correct answer is A: Proper fit of a bicycle helmet. This is the most important safety item to include because head injuries from cycling accidents can be severe or fatal. A properly fitting helmet can reduce the risk of head injuries significantly. It is crucial for the nurse to emphasize the importance of wearing a helmet every time a child rides a bike.
The other choices are incorrect because while shin guards, swimming goggles, and sliding shorts are important for specific sports, they do not have the same level of overall impact on safety as a properly fitting bicycle helmet. It is essential to prioritize the safety item that has the most potential to prevent serious injuries, which in this case is the bicycle helmet.
A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?
- A. Every December is the time to change batteries on the carbon monoxide detector.
- B. I will schedule an appointment with a chimney inspector next week.
- C. If I feel dizzy when using the heater, I need to have it inspected.
- D. When it is cold outside in the winter, I will use a nonvented furnace.
Correct Answer: D
Rationale: The correct answer is D because using a nonvented furnace can lead to carbon monoxide poisoning. Carbon monoxide is a colorless, odorless gas that can be deadly if inhaled in high concentrations. The other choices demonstrate good safety practices such as changing batteries on detectors, scheduling chimney inspections, and recognizing symptoms of heater issues. Using a nonvented furnace is the only unsafe practice mentioned, hence requiring immediate follow-up to educate the patient on the dangers of carbon monoxide poisoning.
The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing?
- A. Young infant
- B. Toddler
- C. Preschooler
- D. Adolescent
Correct Answer: B
Rationale: The correct answer is B: Toddler. Toddlers are at higher risk for lead poisoning due to their hand-to-mouth behavior and increased exposure to lead-containing objects. Young infants are less likely to be mobile and interact with potential sources of lead. Preschoolers and adolescents have lower risk compared to toddlers due to reduced mouthing behavior. Therefore, the nurse is most likely assessing a toddler for lead poisoning.
A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.)
- A. Smoking in bed helps me relax and fall asleep.
- B. We never leave candles burning when we are gone.
- C. We use the same space heater my grandparents used.
- D. We use the RACE method when using the fire extinguisher.
- E. There is a fire extinguisher in the kitchen and garage workshop.
Correct Answer: A,C,D
Rationale: Correct Answer: A, C, D
Rationale:
A: Smoking in bed is a significant fire hazard as it can lead to accidental fires if the individual falls asleep without extinguishing the cigarette. Intervening is crucial to prevent potential disasters.
C: Using an old space heater may pose a safety risk due to outdated technology and potential malfunctions, making it unsafe to use. Intervening is necessary to ensure the safety of the family.
D: Using the RACE method (Rescue, Alarm, Contain, Extinguish) during a fire emergency is important for effective response. Confirming that the family is aware of this method ensures proper handling of fire situations.
Summary:
B: Leaving candles burning unsupervised is a safety concern, but the family's practice of not doing so mitigates the risk.
E: Having fire extinguishers in accessible locations is a good practice for fire safety, indicating preparedness and prevention.
Overall, choices A, C, and D require
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 demonstrates engagement in a repetitive, soothing activity, indicating reduced agitation or restlessness. Choice A shows lack of improvement as the patient is still trying to get up. Choice B suggests dependency on the sitter for comfort. Choice D indicates compliance due to guilt, not necessarily effectiveness of the alternative.