Nokea
The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.)
- A. One family member has gone to lunch.
- B. Patient is placed in bilateral wrist restraints at 0815.
- C. Bilateral radial pulses present 2+ hands warm to touch.
- D. Straps with quick-release buckle attached to bed side rails.
- E. Attempts to distract the patient with television are unsuccessful.
- F. Released from restraints active range-of-motion exercises completed.
Correct Answer: B, C, E, F
Rationale: The correct answers are B, C, E, and F.
B: Documenting the time and type of restraints ensures accurate monitoring and prevents complications.
C: Checking pulses and assessing extremities' warmth is crucial to ensure circulation and prevent injury.
E: Documenting unsuccessful attempts to distract the patient helps assess effectiveness of interventions.
F: Noting the completion of range-of-motion exercises ensures patient safety and compliance with protocols.
Other options are irrelevant or do not directly relate to the safe care of a patient in restraints.
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The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event?
- A. No blood incompatibility occurs with a blood transfusion.
- B. A surgical sponge is left in the patient's incision.
- C. Pulmonary embolism after lung surgery.
- D. Stage II pressure ulcer.
Correct Answer: B
Rationale: The correct answer is B because leaving a surgical sponge in a patient's incision is a Never Event - a preventable medical error that should never occur. Reporting this event is crucial for patient safety and quality care. Choices A, C, and D are not Never Events as they can occur despite adherence to best practices and guidelines. Choice A indicates a successful blood transfusion without complications, C is a known risk after lung surgery, and D can develop even with proper preventive measures.
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.
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 patient has an ankle restraint applied. Upon assessment
- A. the nurse finds the toes a light blue color. Which action will the nurse take next?
- B. Remove the restraint.
- C. Place a blanket over the feet.
- D. Do a complete head-to-toe neurologic assessment.
- E. Take the patient's vital signs.
Correct Answer: A
Rationale: The correct answer is A because a light blue color in the toes indicates poor circulation due to the restraint. The nurse should assess for tissue damage and remove the restraint immediately to restore circulation. Removing the restraint is the priority to prevent further complications. Choice B is incorrect as it doesn't address the circulatory issue. Choices C, D, and E are not the immediate concern and can be addressed after addressing the circulation problem.
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.