Nokea
The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action?
- A. The patient removes the armband to bathe.
- B. The patient wears the red nonslip footwear.
- C. The patient insists on taking a “water†pill in the evening.
- D. The patient who is allergic to penicillin asks the name of a new medicine.
Correct Answer: B
Rationale: The correct answer is B. The patient wearing the red nonslip footwear indicates an understanding of the yellow armband. This is because the yellow armband typically signifies fall risk, and wearing red nonslip footwear is a safety measure to prevent falls. The other choices are incorrect because they do not directly relate to the significance of the yellow armband. Choice A focuses on bathing, choice C on medication timing, and choice D on medication allergies, which are not directly related to fall risk.
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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.
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, which is a significant safety hazard. The nurse should follow up to educate the patient on the dangers of using a nonvented furnace and recommend safer heating alternatives. Choice A is correct as it emphasizes the importance of changing carbon monoxide detector batteries annually. Choice B is correct as scheduling a chimney inspection is a proactive safety measure. Choice C is correct as feeling dizzy while using a heater can indicate a potential issue. Choices E, F, and G are not applicable in this context.
During the admission assessment
- A. the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
- B. The patient is oriented.
- C. The patient takes a hypnotic.
- D. The patient walks 2 miles a day.
- E. The patient recently became widowed.
Correct Answer: B
Rationale: The correct answer is B because orientation indicates the patient's awareness of self, time, and place, affecting their safety awareness. A high level of orientation reduces fall risk as the patient can navigate their environment effectively. Other choices are incorrect as assessing fall risk (A) is important but doesn't directly indicate increased risk, taking a hypnotic (C) may increase fall risk but isn't the most direct indicator, walking 2 miles a day (D) is a positive sign of physical health, and being widowed (E) may impact mental health but doesn't directly relate to fall risk.
The patient is confused
- A. trying to get out of bed
- B. and pulling at the IV tubing. Which nursing diagnosis will the nurse add to the care plan?
- C. Impaired home maintenance
- D. Deficient knowledge
- E. Risk for poisoning
- F. Risk for injury
Correct Answer: D
Rationale: The correct answer is D: Deficient knowledge. The patient's confusion and behavior suggest a lack of understanding regarding the importance of staying in bed and not pulling at the IV tubing. By selecting this nursing diagnosis, the nurse can address the patient's cognitive deficits and provide education to prevent potential harm. Choice A is incorrect as it describes a behavior related to confusion, not a nursing diagnosis. Choice B focuses on the patient's actions rather than the underlying issue of knowledge deficit. Choices C, E, and F are not directly related to the patient's confusion and do not address the root cause of the behavior.
The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
- A. The number for poison control is 800-222-1222.
- B. Never induce vomiting if my grandchild drinks bleach.
- C. I should call 911 if my grandchild loses consciousness.
- D. If my grandchild eats a plant
- E. I should provide syrup of ipecac.
Correct Answer: D
Rationale: Correct Answer: D - If my grandchild eats a plant.
Rationale:
- Eating some plants can be toxic to a child, so it is important to seek medical help immediately.
- Plants can cause serious harm and even be fatal if ingested.
- The other options emphasize important safety measures: calling poison control, not inducing vomiting, and seeking emergency help if the child loses consciousness.
- Providing syrup of ipecac is outdated and not recommended anymore due to potential risks.
- Calling 911 is crucial in emergencies, but the immediate concern with plants is to seek medical advice first.