Nokea
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.
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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 behavior of repeatedly removing the nasogastric tube poses a risk to their safety and health. Restraints may be considered to prevent harm. Refusing to call for help (A) can be addressed through other means. Confusion about time (C) could be due to hospitalization. Difficulty sleeping and requesting items (D) may indicate discomfort but do not necessarily require restraints.
A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?
- A. Remove the restraint.
- B. Place a blanket over the feet.
- C. Immediately do a complete head-to-toe neurologic assessment.
- D. Take the patient's blood pressure pulse temperature and respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Remove the restraint. The blue color in the toes indicates impaired circulation, possibly due to the ankle restraint being too tight. Removing the restraint will allow blood flow to return to the toes and prevent further complications such as tissue damage or necrosis. Choice B is incorrect as it does not address the underlying circulation issue. Choice C is not necessary unless there are other concerning neurological symptoms present. Choice D is important for overall assessment but does not address the immediate issue of impaired circulation.
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. Increased aggressiveness and blood spots on clothing are potential signs of substance abuse in adolescents. This is important information for parents to be aware of as it can indicate a serious issue that needs to be addressed promptly.
Choice B is incorrect because it only partially addresses the issue by mentioning aggressiveness but does not include the specific indication of blood spots on clothing related to substance abuse.
Choice C is incorrect as it focuses on uncoordination and accidents, which is not directly related to the signs of substance abuse mentioned in the question.
Choice D is incorrect as it discusses seat belt use, which is important but not the main focus of the educational session on safety for parents of adolescents.
In summary, choice A is the correct answer because it provides crucial information about potential signs of substance abuse in adolescents, which is relevant to the safety concerns of parents.
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.
Which patient will the nurse see first?
- A. A 56-year-old patient with oxygen with a lighter on the bedside table
- B. A 56-year-old patient with oxygen using an electric razor for grooming
- C. A 1-month-old infant looking at a shiny
- D. round battery just out of arm's reach
- E. A 1-month-old infant with a pacifier that has no string around the baby's neck
Correct Answer: B
Rationale: The nurse will see patient B first because using an electric razor near oxygen can lead to a fire hazard due to the presence of flammable gases. Patient A with a lighter poses a similar risk, but using an electric razor is more immediate. Patient C and D present no immediate danger. Patient E is safe as there is no strangulation risk with the pacifier. Prioritizing safety is crucial in patient care.