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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: Correct Answer: B - The patient wears the red nonslip footwear.
Rationale: The yellow armband typically signifies fall risk in healthcare settings. By wearing red nonslip footwear, the patient demonstrates understanding of the fall risk and the importance of preventing falls. This indicates a good comprehension of the armband's purpose and the need for safety precautions.
Other Choices:
A: The patient removing the armband to bathe does not demonstrate understanding of its significance in preventing falls.
C: Insisting on taking a 'water' pill in the evening is unrelated to the purpose of the yellow armband.
D: Asking about a new medicine when allergic to penicillin does not show understanding of the armband's purpose.
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The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?
- A. Are you able to hear the tornado sirens in your area?
- B. Are you able to read your favorite book?
- C. Are you able to taste spices like before?
- D. Are you able to open a jar of pickles?
Correct Answer: A
Rationale: The correct answer is A: "Are you able to hear the tornado sirens in your area?" This is the most important question because hearing loss is a common age-related physiological change that can affect safety, especially during emergencies like tornadoes. The ability to hear warning signals is crucial for timely response and ensuring the safety of older adults. Choices B, C, and D are not as critical for safety concerns compared to the ability to hear warning sirens. Older adults may use aids for reading, cooking, or opening jars, but compromised hearing can directly impact their ability to respond to emergencies effectively.
The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?
- A. Are you able to hear the tornado sirens in your area?
- B. Are you able to read your favorite book?
- C. Are you able to taste spices like before?
- D. Are you able to open a jar of pickles?
Correct Answer: A
Rationale: The correct answer is A: "Are you able to hear the tornado sirens in your area?" This question is most important as hearing loss is a common age-related physiological change that can affect safety during emergencies. Tornado sirens are crucial for alerting individuals to seek shelter.
Summary of other choices:
B: Reading ability is important but not directly related to safety.
C: Taste changes are common with age but do not impact safety significantly.
D: Difficulty opening jars may occur with age but is not as critical for safety in emergencies.
In this context, asking about hearing the tornado sirens is the most relevant question for ensuring the safety of older adults in an assisted-living facility.
A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
- A. Determining the need for restraints
- B. Assessing the patient's orientation
- C. Obtaining an order for a restraint
- D. Applying the restraint
Correct Answer: D
Rationale: The correct answer is D: Applying the restraint. The rationale is that applying restraints is a task that can be safely delegated to nursing assistive personnel as it involves following specific instructions and does not require complex decision-making. Nursing assistive personnel can be trained to apply restraints safely under the supervision of a registered nurse.
A: Determining the need for restraints requires clinical judgment and assessment skills, which should be done by the registered nurse.
B: Assessing the patient's orientation involves critical thinking and interpretation of assessment findings, which is outside the scope of practice for nursing assistive personnel.
C: Obtaining an order for a restraint requires communication with the healthcare provider and understanding of legal and ethical implications, which should be done by the registered nurse.
A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident?
- A. Pathogenic asepsis
- B. Medical asepsis
- C. Surgical asepsis
- D. Clean asepsis
Correct Answer: C
Rationale: The correct answer is C: Surgical asepsis. During urinary catheter insertion, surgical asepsis is crucial to prevent infection and other procedure-related accidents. Surgical asepsis involves using sterile techniques to minimize the risk of introducing pathogens. The nurse will follow strict protocols such as wearing sterile gloves, using sterile equipment, and maintaining a sterile field. This technique ensures that the urinary catheter is inserted in a sterile environment, reducing the risk of infection. Pathogenic asepsis (A) focuses on destroying pathogens, not preventing their entry during a procedure. Medical asepsis (B) aims to reduce the number of pathogens but does not provide the level of sterility needed for urinary catheter insertion. Clean asepsis (D) involves cleanliness but does not meet the sterile requirements of urinary catheter insertion.
A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
- A. Respiratory rate
- B. Temperature
- C. Apical pulse
- D. Blood pressure
Correct Answer: B
Rationale: The nurse should address the temperature (Choice B) immediately because it is below the normal range (normal range is around 97-99°F). A low body temperature, such as 94.8°F, can indicate hypothermia, which is a medical emergency requiring prompt intervention to prevent complications like organ dysfunction or cardiac arrest. Addressing the temperature first is crucial to prevent further deterioration of the patient's condition.
Other choices are not as urgent:
A: Respiratory rate (12 breaths per minute) is within the normal range.
C: Apical pulse (58 beats per minute) is slightly lower but not immediately life-threatening.
D: Blood pressure (106/56 mmHg) is on the lower side but not acutely concerning.