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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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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.
The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring?
- A. Tile floors, cold food, scratchy linen, and noisy alarms.
- B. Dirty floors, hallways blocked, medication room locked, and alarms set.
- C. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach.
- D. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly.
Correct Answer: D
Rationale: The correct answer is D because wet floors unmarked pose slip hazards, patient pinching fingers in the door indicates lack of safety measures, failure to use a lift for patient increases risk of injury, and alarms not functioning properly can lead to delayed response. Choice A includes minor inconveniences but not significant safety risks. Choice B focuses on facility maintenance rather than direct patient safety risks. Choice C mentions minor issues like empty ice machine and unlocked supply cabinet that do not directly impact patient safety.
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 patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?
- A. 60° to 64° F
- B. 65° to 75° F
- C. 15° to 17° C
- D. 25° to 28° C
Correct Answer: B
Rationale: The correct answer is B: 65° to 75° F. This temperature range is ideal for a patient with respiratory issues experiencing shortness of breath. Lower temperatures can exacerbate breathing difficulties, while higher temperatures may cause discomfort. Maintaining a moderate temperature helps improve air quality and makes it easier for the patient to breathe. Choice A is too cold and could potentially worsen the patient's condition. Choices C and D are in Celsius and are not in the appropriate range for comfort.
Which patient will the nurse see first?
- A. A 56-year-old patient with oxygen with a lighter on the bedside table
- B. A 56-year-old patient with oxygen using an electric razor for grooming
- C. A 1-month-old infant looking at a shiny
- D. round battery just out of arm's reach
- E. A 1-month-old infant with a pacifier that has no string around the baby's neck
Correct Answer: B
Rationale: The nurse will see patient B first because using an electric razor near oxygen can lead to a fire hazard due to the presence of flammable gases. Patient A with a lighter poses a similar risk, but using an electric razor is more immediate. Patient C and D present no immediate danger. Patient E is safe as there is no strangulation risk with the pacifier. Prioritizing safety is crucial in patient care.