Nokea
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 a 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.
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 component of the TUG test to assess mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is important to evaluate balance and stability during the test.
F: Beginning counting after giving instructions ensures an accurate timing of the patient's performance.
Incorrect choices:
A: Ranking a patient as high risk for falls after taking 18 seconds is not accurate as the cutoff time for increased fall risk is typically 12-14 seconds.
B: Teaching the patient to rise from a straight back chair using arms for support is not part of the TUG assessment and may not provide accurate information about the patient's mobility and fall risk.
You may also like to solve these questions
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) because this temperature range is generally considered comfortable for most individuals, including those with respiratory illnesses experiencing shortness of breath. This range provides a balance between being not too cold to trigger discomfort or exacerbate respiratory symptoms and not too warm to cause overheating or breathing difficulties.
Choice A (60° to 64° F) is too cold and may worsen the patient's shortness of breath by causing them to shiver or feel uncomfortable. Choice C (15° to 17° C) is also too cold and may lead to discomfort and potential respiratory distress. Choice D (25° to 28° C) is too warm and can lead to overheating, exacerbating respiratory symptoms and making breathing more difficult.
The nurse enters the patient's room and notices a small fire in the headlight above the bed. In which order will the nurse perform the steps?
- A. Pull the alarm.
- B. Remove the patient.
- C. Use the fire extinguisher.
- D. Close doors and windows.
Correct Answer: A
Rationale: The correct order is A, C, B, D. Pulling the alarm alerts others. Using the fire extinguisher is next to try to extinguish the fire. Removing the patient ensures safety. Closing doors and windows helps contain the fire. Choice A is correct as it prioritizes alerting others to the fire emergency. Choice C is not the first step as the alarm should be pulled before attempting to use the fire extinguisher. Choice B should follow using the fire extinguisher to ensure the patient's safety. Choice D is the last step to prevent the fire from spreading.
A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
- A. Respiratory rate
- B. Temperature
- C. Apical pulse
- D. Blood pressure
Correct Answer: B
Rationale: The nurse should address the temperature (Choice B) immediately because it is below the normal range (normal range is around 97-99°F). A low body temperature, such as 94.8°F, can indicate hypothermia, which is a medical emergency requiring prompt intervention to prevent complications like organ dysfunction or cardiac arrest. Addressing the temperature first is crucial to prevent further deterioration of the patient's condition.
Other choices are not as urgent:
A: Respiratory rate (12 breaths per minute) is within the normal range.
C: Apical pulse (58 beats per minute) is slightly lower but not immediately life-threatening.
D: Blood pressure (106/56 mmHg) is on the lower side but not acutely concerning.
The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.)
- A. Close all doors.
- B. Note evacuation routes.
- C. Note oxygen shut-offs.
- D. Move bedridden patients in their bed.
- E. Wait until the fire department arrives to act.
- F. Use type B fire extinguishers for electrical fires.
Correct Answer: A, B, C, D
Rationale: The correct actions for the nurse to take in this situation are A, B, C, and D. Closing all doors helps contain the fire and smoke. Noting evacuation routes ensures a safe exit plan. Knowing oxygen shut-offs prevents fire hazards. Moving bedridden patients in their beds aids in their evacuation. Choice E is incorrect because waiting for the fire department delays necessary actions. Choice F is incorrect as type B fire extinguishers are not suitable for electrical fires, which require type C extinguishers.
A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident?
- A. Pathogenic asepsis
- B. Medical asepsis
- C. Surgical asepsis
- D. Clean asepsis
Correct Answer: C
Rationale: The correct answer is C: Surgical asepsis. This technique involves creating and maintaining a sterile field to prevent contamination during invasive procedures like catheter insertion. The nurse will use sterile gloves, drapes, and equipment to minimize the risk of infection. Pathogenic asepsis (A) focuses on removing or destroying pathogens but may not ensure sterility. Medical asepsis (B) aims to reduce the number of pathogens but does not achieve a sterile environment. Clean asepsis (D) involves cleanliness but not the level of sterility required for invasive procedures.