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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 question is most important as hearing loss is a common age-related physiological change that can affect safety during emergencies. Tornado sirens are crucial for alerting individuals to seek shelter.
Summary of other choices:
B: Reading ability is important but not directly related to safety.
C: Taste changes are common with age but do not impact safety significantly.
D: Difficulty opening jars may occur with age but is not as critical for safety in emergencies.
In this context, asking about hearing the tornado sirens is the most relevant question for ensuring the safety of older adults in an assisted-living facility.
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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.
The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take?
- A. Assess the patient.
- B. Gather restraint supplies.
- C. Try alternatives to restraint.
- D. Call the health care provider for a restraint order.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient. The nurse's priority is to assess the patient to determine the cause of sudden confusion and agitation. This may be due to various reasons such as hypoxia, hypoglycemia, infection, or medication side effects. Assessing the patient's vital signs, oxygen saturation, blood glucose level, and reviewing medication administration can help identify the underlying cause. Gathering restraint supplies (B) should not be the initial action as it may not address the root cause of the confusion and can lead to further agitation. Trying alternatives to restraint (C) is important, but assessing the patient should come first. Calling the healthcare provider for a restraint order (D) should only be considered after other interventions have been attempted.
The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing?
- A. Young infant
- B. Toddler
- C. Preschooler
- D. Adolescent
Correct Answer: B
Rationale: The correct answer is B: Toddler. Toddlers are at highest risk for lead poisoning due to their habit of putting objects in their mouths. Lead exposure can come from old paint, soil, or water. Young infants have less exposure due to limited mobility. Preschoolers are less at risk as they are less likely to engage in mouthing behaviors. Adolescents have lower risk as they are less likely to come into contact with lead sources.
A home health nurse is assessing a family's home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up?
- A. Plastic grocery bags are neatly stored under the counter.
- B. Electric outlets are covered in all rooms.
- C. No bumper pads are in the crib.
- D. Crib slats are 5 cm apart.
Correct Answer: A
Rationale: The correct answer is A because storing plastic grocery bags under the counter poses a suffocation risk to the toddler. Toddlers could access the bags and potentially suffocate if they put a bag over their head. This finding requires immediate follow-up to ensure the safety of the child.
Choice B is incorrect because covering electric outlets is a safety measure for toddlers, not a cause for follow-up. Choice C is also incorrect because not having bumper pads in the crib is actually recommended for safe sleep practices. Choice D is incorrect as well since crib slats being 5 cm apart is within the safety guidelines.
The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action?
- A. The patient removes the armband to bathe.
- B. The patient wears the red nonslip footwear.
- C. The patient insists on taking a “water†pill in the evening.
- D. The patient who is allergic to penicillin asks the name of a new medicine.
Correct Answer: B
Rationale: The correct answer is B. The patient wearing the red nonslip footwear indicates an understanding of the yellow armband. This is because the yellow armband typically signifies fall risk, and wearing red nonslip footwear is a safety measure to prevent falls. The other choices are incorrect because they do not directly relate to the significance of the yellow armband. Choice A focuses on bathing, choice C on medication timing, and choice D on medication allergies, which are not directly related to fall risk.