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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 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.
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The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. Which priority concern will require collaboration with social services?
- A. The electricity was turned off 3 days ago.
- B. The water comes from the county water supply.
- C. A son and family recently moved into the home.
- D. This home is not furnished with a microwave oven.
Correct Answer: A
Rationale: The correct answer is A because the electricity being turned off poses a significant risk to the older-adult patient's health and safety. Lack of electricity can lead to spoiled food, inability to cook or store food properly, and compromised medical equipment like refrigerated medications. Collaboration with social services is necessary to address this immediate concern. Choices B, C, and D are less critical as county water supply is generally safe, a son moving in is not directly related to the patient's condition, and lack of a microwave oven is not as urgent as lack of electricity in this situation.
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.
Correct Answer: B,C,E,F
Rationale: Correct Answer: B, C, E, F
Rationale:
B: Documenting the specific time and type of restraints applied ensures accurate monitoring and compliance with protocols.
C: Noting the presence and quality of radial pulses helps in assessing circulation and preventing complications related to restraints.
E: Documenting unsuccessful attempts to distract the patient with television indicates efforts made to address the patient's needs.
F: Recording any interventions or actions taken is crucial for continuity of care and legal documentation.
Summary:
A: Irrelevant to the patient's care in restraints.
D: Focuses on the equipment used rather than patient assessment.
G: No information provided to evaluate this option.
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 to prevent transmission of pathogens as hands are the most common mode of transmission. Washing hands effectively removes microorganisms, reducing the risk of infection. The other choices are incorrect because washing the wound only addresses local hygiene, wearing gloves and eye protection are important but secondary to hand hygiene in preventing transmission of pathogens.
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.
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.