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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 it includes examples of safety risks that directly impact patient well-being. Wet floors unmarked can lead to slips and falls. Patient pinching fingers in the door is a physical hazard. Failure to use a lift for a patient can cause injury to both the patient and staff. Alarms not functioning properly can delay response to emergencies.
Explanation for other choices:
A: Tile floors, cold food, scratchy linen, and noisy alarms are not direct safety risks that pose immediate harm to patients.
B: Dirty floors, blocked hallways, and alarms set are not specific examples of patient safety risks.
C: Carpeted floors, ice machine empty, and call light in reach are not significant safety risks compared to the examples in choice D.
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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.
A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
- A. Determining the need for restraints
- B. Assessing the patient's orientation
- C. Obtaining an order for a restraint
- D. Applying the restraint
Correct Answer: D
Rationale: The correct answer is D: Applying the restraint. The rationale is that nursing assistive personnel can perform tasks that involve direct patient care under the supervision of a nurse. Applying restraints is a task that involves following specific guidelines and does not require critical thinking or decision-making skills. Tasks A, B, and C involve assessing, determining the need, and obtaining orders for restraints, which require nursing judgment and cannot be delegated to nursing assistive personnel. Other choices are left blank as they are not relevant to the question.
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.
The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.)
- A. Where did you fall?
- B. What time did the fall occur?
- C. What were you doing when you fell?
- D. What types of injuries occurred after the fall?
- E. Did you obtain an electronic safety alert device after the fall?
- F. What are your medical problems that may have caused the fall?
Correct Answer: A, B, C, D
Rationale: The correct answers are A, B, C, and D. The SPLATT acronym stands for Symptoms, Previous falls, Location, Activity, Time, and Trauma. Therefore, the nurse should ask where the fall happened (A), what the patient was doing when they fell (C), and what types of injuries occurred after the fall (D) to assess the circumstances surrounding the fall. Asking about the time of the fall (B) helps determine if there are any time-related factors contributing to the fall. These questions provide crucial information for assessing the patient's risk factors and potential interventions. Choices E and F are incorrect because they do not directly pertain to the SPLATT components and may not provide as relevant information for assessing the fall risk in this situation.