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.
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A patient has an ankle restraint applied. Upon assessment
- A. the nurse finds the toes a light blue color. Which action will the nurse take next?
- B. Remove the restraint.
- C. Place a blanket over the feet.
- D. Do a complete head-to-toe neurologic assessment.
- E. Take the patient's vital signs.
Correct Answer: A
Rationale: The correct answer is A because a light blue color in the toes indicates poor circulation due to the restraint. The nurse should assess for tissue damage and remove the restraint immediately to restore circulation. Removing the restraint is the priority to prevent further complications. Choice B is incorrect as it doesn't address the circulatory issue. Choices C, D, and E are not the immediate concern and can be addressed after addressing the circulation problem.
The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?
- A. Are you able to hear the tornado sirens in your area?
- B. Are you able to read your favorite book?
- C. Are you able to taste spices like before?
- D. Are you able to open a jar of pickles?
Correct Answer: A
Rationale: The correct answer is A: "Are you able to hear the tornado sirens in your area?" This is the most important question because hearing loss is a common age-related physiological change that can affect safety, especially during emergencies like tornadoes. The ability to hear warning signals is crucial for timely response and ensuring the safety of older adults. Choices B, C, and D are not as critical for safety concerns compared to the ability to hear warning sirens. Older adults may use aids for reading, cooking, or opening jars, but compromised hearing can directly impact their ability to respond to emergencies effectively.
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 nurse is providing safety information regarding accidental poisoning to a grandparent. Which comment requires nurse intervention?
- A. The poison control number is 800-222-1222.
- B. Never induce vomiting if bleach is ingested.
- C. I should call 911 if my grandchild loses consciousness.
- D. If my grandchild eats a plant, I should provide syrup of ipecac.
Correct Answer: D
Rationale: The correct answer is D because providing syrup of ipecac to induce vomiting is no longer recommended for poisoning treatment. The American Academy of Pediatrics advises against the use of syrup of ipecac due to potential harm and lack of proven benefit. Inducing vomiting can cause further harm and delay appropriate medical treatment. A, B, and C are correct choices as they emphasize important safety measures such as contacting poison control, avoiding inducing vomiting for bleach ingestion, and calling 911 if the grandchild loses consciousness.
A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?
- A. Identifies patient with one identifier before transporting to x-ray department
- B. Initiates an intravenous (IV) catheter using clean technique on the first try
- C. Uses medication bar coding when administering medications
- D. Obtains vital signs to place on a surgical patient's chart
Correct Answer: C
Rationale: The correct answer is C because using medication bar coding ensures the right medication is given to the right patient at the right time, aligning with National Patient Safety Goals to prevent medication errors. This process enhances patient safety by verifying the medication through scanning before administration.
Choice A may be a good practice, but it does not directly relate to a specific patient safety goal. Choice B focuses on IV catheter insertion technique, which is important but not specifically related to patient safety goals. Choice D is important for patient care but doesn't directly address medication safety.