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The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take?
- A. Assess the patient.
- B. Gather restraint supplies.
- C. Try alternatives to restraint.
- D. Call the health care provider for a restraint order.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient. The nurse's priority is to assess the patient to determine the cause of sudden confusion and agitation. This may be due to various reasons such as hypoxia, hypoglycemia, infection, or medication side effects. Assessing the patient's vital signs, oxygen saturation, blood glucose level, and reviewing medication administration can help identify the underlying cause. Gathering restraint supplies (B) should not be the initial action as it may not address the root cause of the confusion and can lead to further agitation. Trying alternatives to restraint (C) is important, but assessing the patient should come first. Calling the healthcare provider for a restraint order (D) should only be considered after other interventions have been attempted.
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An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient?
- A. Positions patient's buttocks close to the front of wheelchair seat
- B. Backs wheelchair into elevator
- C. leading with large rear wheels first
- D. Places locked wheelchair on same side of bed as patient's weaker side
- E. Unlocks wheelchair for easy maneuverability when patient is transferring
Correct Answer: B
Rationale: The correct answer is B: Backs wheelchair into elevator. This action ensures that the patient is facing forward during transport, reducing the risk of injury. Positioning the patient's buttocks close to the front of the wheelchair seat (Choice A) may cause instability. Leading with large rear wheels first (Choice C) can lead to tipping. Placing a locked wheelchair on the same side of the bed as the patient's weaker side (Choice D) may hinder safe transfer. Unlocking the wheelchair for easy maneuverability (Choice E) is important but not specifically related to safe transport.
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 inform the healthcare provider about the incident to ensure proper evaluation and follow-up care. This step is crucial in addressing any potential underlying issues that may have led to the fall and preventing future falls. Notifying the healthcare provider also ensures that the patient's safety and well-being are prioritized.
Choice A (Do nothing) is incorrect because the patient falling out of bed is a significant incident that requires further action. Choice C (Complete an incident report) is not the immediate next step as notifying the healthcare provider takes precedence. Choice D (Assess the patient) has already been done, so it is not the next necessary action.
A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?
- A. Wash hands
- B. Wash wound
- C. Wear gloves
- D. Wear eye protection
Correct Answer: A
Rationale: The correct answer is A: Wash hands. This technique is crucial in preventing the transmission of pathogens because hands are a common mode of pathogen spread. Washing hands effectively removes pathogens and reduces the risk of infection. Choice B (Wash wound) is important for wound care but not as effective in preventing transmission of pathogens. Choice C (Wear gloves) is important for personal protection but does not address the primary mode of transmission. Choice D (Wear eye protection) is not directly related to preventing transmission through hand hygiene. It is essential to prioritize hand hygiene as the most effective method of preventing the spread of pathogens.
The nurse is performing the “Timed Get Up and Go (TUG)†assessment. Which actions will the nurse take? (Select all that apply.)
- A. Ranks a patient as high risk for falls after patient takes 18 seconds to complete
- B. Teaches patient to rise from straight back chair using arms for support
- C. Instructs the patient to walk 10 feet as quickly and safely as possible
- D. Observes for unsteadiness in patient's gait
- E. Begins counting after the instructions
- F. Allows the patient a practice trial.
Correct Answer: C, D, F
Rationale: The correct answers are C, D, and F.
C: Instructing the patient to walk 10 feet quickly and safely is a key step in the TUG assessment to evaluate mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is crucial to assess balance and risk of falls during the TUG assessment.
F: Allowing the patient a practice trial helps ensure that they understand the instructions and can perform the task accurately during the actual assessment.
These actions are essential for a comprehensive and accurate evaluation of the patient's mobility and fall risk during the Timed Get Up and Go assessment.
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 typically signifies that a patient has chosen do not resuscitate (DNR) status. This means that the patient has made a decision to not receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. This information is crucial for healthcare providers to know and respect the patient's wishes. The other choices are incorrect because a purple wristband does not indicate allergies (A), fall risk (C), or seizure risk (D). It is essential for the nurse to be aware of the significance of different colored wristbands to provide appropriate care and respect the patient's autonomy.