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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.
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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.
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 experiencing respiratory distress as it helps maintain a comfortable environment without being too cold or too warm. Lower temperatures (choice A) can exacerbate breathing difficulties, while the temperature range in Celsius (choice C) is too low for comfort. The temperature range in choice D is too warm and may cause discomfort for the patient. It is important to maintain a moderate temperature to assist the patient in breathing comfortably.
A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session?
- A. Run wires under the carpet.
- B. Disconnect items before cleaning.
- C. Grasp the cord when unplugging items.
- D. Use masking tape to secure cords to the floor.
Correct Answer: B
Rationale: The correct answer is B: Disconnect items before cleaning. This is the safest way to prevent electrical shock as it ensures that no electrical current is flowing through the items being cleaned. Running wires under the carpet (A) can create a tripping hazard and increase the risk of damage to the wires. Grasping the cord when unplugging items (C) can lead to accidental contact with live wires. Using masking tape to secure cords to the floor (D) can damage the cords and increase the risk of tripping. Therefore, disconnecting items before cleaning is the most effective way to prevent electrical shock.
The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working?
- A. The patient continues to get up from the chair at the nurses' station.
- B. The patient gets restless when the sitter leaves for lunch.
- C. The patient folds three washcloths over and over.
- D. The patient apologizes for being 'such a bother.'
Correct Answer: C
Rationale: The correct answer is C because the patient folding three washcloths over and over demonstrates engagement in a repetitive, soothing activity, indicating reduced agitation or restlessness. Choice A shows lack of improvement as the patient is still trying to get up. Choice B suggests dependency on the sitter for comfort. Choice D indicates compliance due to guilt, not necessarily effectiveness of the alternative.
A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?
- A. Check on the patient once a shift.
- B. Encourage visitors in the early evening.
- C. Place all four side rails in the 'up' position.
- D. Keep the patient on fall risk until discharge.
Correct Answer: D
Rationale: The correct answer is D: Keep the patient on fall risk until discharge. This is because fall precautions should be maintained throughout the patient's stay to ensure their safety. Checking on the patient once a shift (A) may not be sufficient to prevent falls. Encouraging visitors in the early evening (B) could distract the patient and increase fall risk. Placing all four side rails in the 'up' position (C) can lead to entrapment or injury. Therefore, the best practice is to keep the patient on fall risk until discharge to maintain a high level of vigilance and prevent falls effectively.