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The nurse is performing the “Timed Get Up and Go (TUG)†assessment. Which actions will the nurse take? (Select all that apply.)
- A. Ranks a patient as high risk for falls after patient takes 18 seconds to complete
- B. Teaches patient to rise from straight back chair using arms for support
- C. Instructs the patient to walk 10 feet as quickly and safely as possible
- D. Observes for unsteadiness in patient's gait
- E. Begins counting after the instructions
- F. Allows the patient a practice trial.
Correct Answer: C, D, F
Rationale: The correct answers are C, D, and F.
C: Instructing the patient to walk 10 feet quickly and safely is a key step in the TUG assessment to evaluate mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is crucial to assess balance and risk of falls during the TUG assessment.
F: Allowing the patient a practice trial helps ensure that they understand the instructions and can perform the task accurately during the actual assessment.
These actions are essential for a comprehensive and accurate evaluation of the patient's mobility and fall risk during the Timed Get Up and Go assessment.
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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 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 enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one?
- A. Pull the alarm.
- B. Remove the patient.
- C. Use the fire extinguisher.
- D. Close doors and windows.
Correct Answer: A
Rationale: The correct order is A: Pull the alarm. In case of a fire, alerting others is the first priority to ensure everyone's safety. This step will notify the fire department and initiate evacuation procedures. Removing the patient (B) should be done after sounding the alarm to prevent harm. Using the fire extinguisher (C) comes after ensuring the alarm is activated. Closing doors and windows (D) is important to contain the fire but should be done after alerting others and removing the patient.
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.
During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
- A. The patient is oriented.
- B. The patient takes a hypnotic.
- C. The patient walks 2 miles a day.
- D. The patient recently became widowed.
Correct Answer: B
Rationale: The correct answer is B: The patient takes a hypnotic. Patients taking hypnotic medications are at an increased risk for falls due to the sedative effects of these drugs, causing dizziness, impaired balance, and confusion. This increases the likelihood of accidents and falls.
Incorrect Choices:
A: The patient is oriented. Being oriented does not necessarily indicate a decreased risk for falls.
C: The patient walks 2 miles a day. Regular exercise is beneficial for overall health but does not directly correlate with fall risk.
D: The patient recently became widowed. While emotional distress can affect a person's well-being, it does not directly indicate an increased risk for falls.
Which activity will cause the nurse to monitor for equipment-related accidents?
- A. Uses a patient-controlled analgesic pump
- B. Uses a computer-based documentation record
- C. Uses a measuring device that measures urine
- D. Uses a manual medication-dispensing device
Correct Answer: A
Rationale: The correct answer is A because using a patient-controlled analgesic pump involves complex equipment that can malfunction or be misused, leading to potential accidents like overmedication or pump failure. Monitoring is crucial to prevent harm. Choices B and C involve routine equipment use without high risk for accidents. Choice D is more straightforward and less prone to accidents compared to the complex analgesic pump.