Nokea
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.
You may also like to solve these questions
A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?
- A. Identifies patient with one identifier before transport
- B. Initiates IV catheter using clean technique
- C. Uses medication bar coding
- D. Obtains vital signs for surgical chart
Correct Answer: C
Rationale: The correct answer is C: Uses medication bar coding. This action aligns with the National Patient Safety Goals by helping to ensure accurate medication administration through technology. Bar coding reduces the risk of medication errors by verifying the right patient, medication, dose, route, and time. Option A is important but does not specifically align with the National Patient Safety Goals. Option B mentions clean technique, but sterile technique is required for IV catheter insertion. Option D is important for surgical preparation but does not directly relate to patient safety goals.
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.
A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?
- A. Check on the patient once a shift.
- B. Encourage visitors in the early evening.
- C. Place all four side rails in the 'up' position.
- D. Keep the patient on fall risk until discharge.
Correct Answer: D
Rationale: The correct answer is D because keeping the patient on fall risk until discharge ensures continuous monitoring and implementation of fall precautions. Checking on the patient once a shift (Option A) is not enough for a high fall risk patient. Encouraging visitors in the early evening (Option B) may distract the patient and increase the risk of falls. Placing all four side rails in the 'up' position (Option C) can lead to entrapment and is not recommended. Keeping the patient on fall risk until discharge (Option D) ensures consistent vigilance and preventive measures.
A home health nurse is assessing a family's home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up?
- A. Plastic grocery bags are neatly stored under the counter.
- B. Electric outlets are covered in all rooms.
- C. No bumper pads are in the crib.
- D. Crib slats are 5 cm apart.
Correct Answer: A
Rationale: The correct answer is A because storing plastic grocery bags under the counter poses a suffocation risk to the toddler. Toddlers could access the bags and potentially suffocate if they put a bag over their head. This finding requires immediate follow-up to ensure the safety of the child.
Choice B is incorrect because covering electric outlets is a safety measure for toddlers, not a cause for follow-up. Choice C is also incorrect because not having bumper pads in the crib is actually recommended for safe sleep practices. Choice D is incorrect as well since crib slats being 5 cm apart is within the safety guidelines.
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.