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The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.)
- A. Water outdoor plants with a nozzle and hose.
- B. Walk to the mailbox in the summer.
- C. Encourage yearly eye examinations.
- D. Use bathtubs without safety strips.
- E. Keep pathways clutter free.
Correct Answer: B, C, E
Rationale: Correct Answer: B, C, E
Rationale:
- B: Walking regularly helps maintain strength and balance, reducing fall risk.
- C: Yearly eye exams can detect vision problems that contribute to falls.
- E: Clear pathways prevent tripping hazards, reducing the risk of falls.
Incorrect Choices:
- A: Watering plants is unrelated to fall prevention.
- D: Bathtubs without safety strips increase fall risk.
- F, G: No additional choices given.
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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 home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.)
- A. Smoking in bed helps me relax and fall asleep.
- B. We never leave candles burning when we are gone.
- C. We use the same space heater my grandparents used.
- D. We use the RACE method when using the fire extinguisher.
- E. There is a fire extinguisher in the kitchen and garage workshop.
Correct Answer: A, C, D
Rationale: The correct answers are A, C, D.
A: Smoking in bed poses a significant fire hazard due to the risk of falling asleep while smoking, leading to potential ignition of bed linens.
C: Using an old space heater may increase the risk of malfunction and fire hazards, as older models may not have modern safety features.
D: Using the RACE method for fire extinguisher use (Rescue, Alarm, Contain, Extinguish) is incorrect; the correct method is PASS (Pull, Aim, Squeeze, Sweep).
B, E: Leaving candles burning and having fire extinguishers accessible are good fire safety practices.
In summary, choices A, C, and D warrant intervention due to the increased risk of fire hazards, while choices B and E demonstrate good fire safety habits.
A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?
- A. Every December is the time to change batteries on the carbon monoxide detector.
- B. I will schedule an appointment with a chimney inspector next week.
- C. If I feel dizzy when using the heater, I need to have it inspected.
- D. When it is cold outside in the winter, I will use a nonvented furnace.
Correct Answer: D
Rationale: The correct answer is D because using a nonvented furnace can lead to carbon monoxide poisoning, which is a significant safety hazard. The nurse should follow up to educate the patient on the dangers of using a nonvented furnace and recommend safer heating alternatives. Choice A is correct as it emphasizes the importance of changing carbon monoxide detector batteries annually. Choice B is correct as scheduling a chimney inspection is a proactive safety measure. Choice C is correct as feeling dizzy while using a heater can indicate a potential issue. Choices E, F, and G are not applicable in this context.
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 a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session?
- A. Proper fit of a bicycle helmet.
- B. Proper fit of soccer shin guards.
- C. Proper fit of swimming goggles.
- D. Proper fit of baseball sliding shorts.
Correct Answer: A
Rationale: The correct answer is A: Proper fit of a bicycle helmet. This is the most important safety item to include because head injuries from bicycle accidents can be life-threatening. Properly fitting helmets can significantly reduce the risk of head injuries. Soccer shin guards, swimming goggles, and baseball sliding shorts are important for their respective activities, but they do not have the same potential life-saving impact as a bicycle helmet. It is crucial for the nurse to emphasize the importance of wearing a properly fitting helmet to prevent head injuries during biking.