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A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?
- A. Check on the patient once a shift.
- B. Encourage visitors in the early evening.
- C. Place all four side rails in the 'up' position.
- D. Keep the patient on fall risk until discharge.
Correct Answer: D
Rationale: The correct answer is D because keeping the patient on fall risk until discharge ensures continuous monitoring and implementation of fall precautions. Checking on the patient once a shift (Option A) is not enough for a high fall risk patient. Encouraging visitors in the early evening (Option B) may distract the patient and increase the risk of falls. Placing all four side rails in the 'up' position (Option C) can lead to entrapment and is not recommended. Keeping the patient on fall risk until discharge (Option D) ensures consistent vigilance and preventive measures.
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A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session?
- A. Proper fit of a bicycle helmet
- B. Proper fit of soccer shin guards
- C. Proper fit of swimming goggles
- D. Proper fit of baseball sliding shorts
Correct Answer: A
Rationale: The correct answer is A: Proper fit of a bicycle helmet. This is the most important safety item to include because head injuries from cycling accidents can be severe or fatal. A properly fitting helmet can reduce the risk of head injuries significantly. It is crucial for the nurse to emphasize the importance of wearing a helmet every time a child rides a bike.
The other choices are incorrect because while shin guards, swimming goggles, and sliding shorts are important for specific sports, they do not have the same level of overall impact on safety as a properly fitting bicycle helmet. It is essential to prioritize the safety item that has the most potential to prevent serious injuries, which in this case is the bicycle helmet.
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: Correct Answer: A, C, D
Rationale:
A: Smoking in bed is a significant fire hazard as it can lead to accidental fires if the individual falls asleep without extinguishing the cigarette. Intervening is crucial to prevent potential disasters.
C: Using an old space heater may pose a safety risk due to outdated technology and potential malfunctions, making it unsafe to use. Intervening is necessary to ensure the safety of the family.
D: Using the RACE method (Rescue, Alarm, Contain, Extinguish) during a fire emergency is important for effective response. Confirming that the family is aware of this method ensures proper handling of fire situations.
Summary:
B: Leaving candles burning unsupervised is a safety concern, but the family's practice of not doing so mitigates the risk.
E: Having fire extinguishers in accessible locations is a good practice for fire safety, indicating preparedness and prevention.
Overall, choices A, C, and D require
During the admission assessment
- A. the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
- B. The patient is oriented.
- C. The patient takes a hypnotic.
- D. The patient walks 2 miles a day.
- E. The patient recently became widowed.
Correct Answer: B
Rationale: The correct answer is B because orientation indicates the patient's awareness of self, time, and place, affecting their safety awareness. A high level of orientation reduces fall risk as the patient can navigate their environment effectively. Other choices are incorrect as assessing fall risk (A) is important but doesn't directly indicate increased risk, taking a hypnotic (C) may increase fall risk but isn't the most direct indicator, walking 2 miles a day (D) is a positive sign of physical health, and being widowed (E) may impact mental health but doesn't directly relate to fall risk.
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 providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
- A. The number for poison control is 800-222-1222.
- B. Never induce vomiting if my grandchild drinks bleach.
- C. I should call 911 if my grandchild loses consciousness.
- D. If my grandchild eats a plant
- E. I should provide syrup of ipecac.
Correct Answer: D
Rationale: Correct Answer: D - If my grandchild eats a plant.
Rationale:
- Eating some plants can be toxic to a child, so it is important to seek medical help immediately.
- Plants can cause serious harm and even be fatal if ingested.
- The other options emphasize important safety measures: calling poison control, not inducing vomiting, and seeking emergency help if the child loses consciousness.
- Providing syrup of ipecac is outdated and not recommended anymore due to potential risks.
- Calling 911 is crucial in emergencies, but the immediate concern with plants is to seek medical advice first.