Nokea
The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care?
- A. Risk for falls
- B. Deficient knowledge
- C. Risk for suffocation
- D. Impaired physical mobility
Correct Answer: B
Rationale: Correct Answer: B - Deficient knowledge
Rationale: The nurse's assessment indicates that the patient lacks the knowledge to properly apply the sequential compression devices, leading to them being put on upside down. This nursing diagnosis reflects the patient's need for education on device application to prevent potential harm.
Summary of other choices:
A: Risk for falls - Not directly related to the incorrect application of sequential compression devices.
C: Risk for suffocation - Not relevant to the situation described.
D: Impaired physical mobility - Incorrect application of devices does not necessarily indicate impaired physical mobility.
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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.
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 the use of medical equipment that can malfunction or be misused, potentially leading to accidents such as medication overdose. The nurse needs to monitor the equipment closely to ensure it is functioning properly and the patient is using it correctly. Choices B, C, and D do not involve equipment that poses a high risk of accidents if not monitored closely. Computer-based documentation records, measuring devices for urine, and manual medication-dispensing devices are all important tools for nurses, but they are less likely to result in equipment-related accidents compared to a patient-controlled analgesic pump.
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 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 transport
- B. Initiates IV catheter using clean technique
- C. Uses medication bar coding
- D. Obtains vital signs for surgical chart
Correct Answer: C
Rationale: The correct answer is C: Uses medication bar coding. This action aligns with the National Patient Safety Goals by helping to ensure accurate medication administration through technology. Bar coding reduces the risk of medication errors by verifying the right patient, medication, dose, route, and time. Option A is important but does not specifically align with the National Patient Safety Goals. Option B mentions clean technique, but sterile technique is required for IV catheter insertion. Option D is important for surgical preparation but does not directly relate to patient safety goals.
The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. Which priority concern will require collaboration with social services?
- A. The electricity was turned off 3 days ago.
- B. The water comes from the county water supply.
- C. A son and family recently moved into the home.
- D. This home is not furnished with a microwave oven.
Correct Answer: A
Rationale: The correct answer is A because the electricity being turned off poses a significant risk to the older-adult patient's health and safety. Lack of electricity can lead to spoiled food, inability to cook or store food properly, and compromised medical equipment like refrigerated medications. Collaboration with social services is necessary to address this immediate concern. Choices B, C, and D are less critical as county water supply is generally safe, a son moving in is not directly related to the patient's condition, and lack of a microwave oven is not as urgent as lack of electricity in this situation.