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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: The correct answers are A, C, D.
A: Smoking in bed poses a significant fire hazard due to the risk of falling asleep while smoking, leading to potential ignition of bed linens.
C: Using an old space heater may increase the risk of malfunction and fire hazards, as older models may not have modern safety features.
D: Using the RACE method for fire extinguisher use (Rescue, Alarm, Contain, Extinguish) is incorrect; the correct method is PASS (Pull, Aim, Squeeze, Sweep).
B, E: Leaving candles burning and having fire extinguishers accessible are good fire safety practices.
In summary, choices A, C, and D warrant intervention due to the increased risk of fire hazards, while choices B and E demonstrate good fire safety habits.
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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 indicates engagement in a task, showing decreased restlessness or agitation. This behavior suggests the patient is able to focus on a repetitive and soothing activity, indicating successful use of alternatives to restraint. Choice A shows continued restlessness, choice B demonstrates dependence on the sitter, and choice D indicates the patient's emotional response, none of which directly reflect the effectiveness of the alternative intervention.
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.
A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?
- A. Wash hands
- B. Wash wound
- C. Wear gloves
- D. Wear eye protection
Correct Answer: A
Rationale: The correct answer is A: Wash hands. This technique is crucial to prevent transmission of pathogens as hands are the most common mode of transmission. Washing hands effectively removes microorganisms, reducing the risk of infection. The other choices are incorrect because washing the wound only addresses local hygiene, wearing gloves and eye protection are important but secondary to hand hygiene in preventing transmission of pathogens.
The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. Which priority concern will require collaboration with social services to address the patient's health care needs?
- A. The electricity was turned off 3 days ago.
- B. The water comes from the county water supply.
- C. A son and family recently moved into the home.
- D. This home is not furnished with a microwave oven.
Correct Answer: A
Rationale: The correct answer is A. The priority concern that requires collaboration with social services is the electricity being turned off 3 days ago. This is crucial because without electricity, the patient's access to essential medical devices, such as a refrigerator for storing medications or a nebulizer for breathing treatments, is compromised. Social services can help address this issue by connecting the patient with resources for utility assistance or temporary housing.
Choice B is incorrect because access to county water supply is not directly related to the patient's immediate health care needs in this scenario. Choice C is also incorrect as the son and family moving in is not a priority concern requiring collaboration with social services. Choice D is not a priority concern either, as the lack of a microwave oven does not impact the patient's health care needs significantly.
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.
Correct Answer: A,B,C,D
Rationale: The correct actions for the nurse to take in this scenario are A, B, C, and D. Closing all doors helps contain the fire and smoke, protecting patients. Noting evacuation routes ensures a quick and safe exit strategy if needed. Identifying oxygen shut-offs prevents potential fuel for a fire. Moving bedridden patients in their bed is crucial for their safety and transportability. Waiting for the fire department (choice E) is not recommended as immediate action by the nurse is necessary to ensure patient safety.