Nokea
The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?
- A. Increased aggressiveness and blood spots on clothing may indicate substance abuse.
- B. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing.
- C. Adolescents need information about the effects of uncoordination on accidents.
- D. Adolescents need to be reminded to use seat belts primarily on long trips.
Correct Answer: A
Rationale: The correct answer is A because increased aggressiveness and blood spots on clothing are potential signs of substance abuse in adolescents. Aggressiveness and physical changes can indicate underlying issues like substance abuse, which is crucial for parents to recognize for intervention. B is incorrect because aggressiveness alone is not a definitive clue for substance abuse. C is incorrect as it focuses on uncoordination rather than specific signs of substance abuse. D is incorrect as it is a general safety reminder and not specific to substance abuse indicators.
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An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient?
- A. Positions patient's buttocks close to the front of wheelchair seat
- B. Backs wheelchair into elevator
- C. leading with large rear wheels first
- D. Places locked wheelchair on same side of bed as patient's weaker side
- E. Unlocks wheelchair for easy maneuverability when patient is transferring
Correct Answer: B
Rationale: The correct answer is B: Backs wheelchair into elevator. This action ensures that the patient is facing forward during transport, reducing the risk of injury. Positioning the patient's buttocks close to the front of the wheelchair seat (Choice A) may cause instability. Leading with large rear wheels first (Choice C) can lead to tipping. Placing a locked wheelchair on the same side of the bed as the patient's weaker side (Choice D) may hinder safe transfer. Unlocking the wheelchair for easy maneuverability (Choice E) is important but not specifically related to safe transport.
The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint?
- A. The patient refuses to call for help to go to the bathroom.
- B. The patient continues to remove the nasogastric tube.
- C. The patient gets confused regarding the time at night.
- D. The patient does not sleep and continues to ask for items.
Correct Answer: B
Rationale: The correct answer is B because the patient's action of repeatedly removing the nasogastric tube poses a direct risk to their health and safety. This behavior indicates a lack of understanding or ability to comprehend the importance of the tube in their care. Restraints may be necessary to prevent harm in this situation. Refusing to call for help, confusion about time, and insomnia do not directly indicate a need for restraints. These behaviors may require further assessment and interventions, but they do not pose an immediate threat to the patient's well-being like removing a necessary medical device.
The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.)
- A. One family member has gone to lunch.
- B. Patient is placed in bilateral wrist restraints at 0815.
- C. Bilateral radial pulses present 2+ hands warm to touch.
- D. Straps with quick-release buckle attached to bed side rails.
- E. Attempts to distract the patient with television are unsuccessful.
- F. Released from restraints active range-of-motion exercises completed.
Correct Answer: B, C, E, F
Rationale: The correct answers are B, C, E, and F.
B: Documenting the time and type of restraints ensures accurate monitoring and prevents complications.
C: Checking pulses and assessing extremities' warmth is crucial to ensure circulation and prevent injury.
E: Documenting unsuccessful attempts to distract the patient helps assess effectiveness of interventions.
F: Noting the completion of range-of-motion exercises ensures patient safety and compliance with protocols.
Other options are irrelevant or do not directly relate to the safe care of a patient in restraints.
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: Correct Answer: A, C, D
Rationale:
A: Smoking in bed is a significant fire hazard as it can lead to accidental fires if the individual falls asleep without extinguishing the cigarette. Intervening is crucial to prevent potential disasters.
C: Using an old space heater may pose a safety risk due to outdated technology and potential malfunctions, making it unsafe to use. Intervening is necessary to ensure the safety of the family.
D: Using the RACE method (Rescue, Alarm, Contain, Extinguish) during a fire emergency is important for effective response. Confirming that the family is aware of this method ensures proper handling of fire situations.
Summary:
B: Leaving candles burning unsupervised is a safety concern, but the family's practice of not doing so mitigates the risk.
E: Having fire extinguishers in accessible locations is a good practice for fire safety, indicating preparedness and prevention.
Overall, choices A, C, and D require
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.