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When making rounds the nurse observes a purple wristband on a patient's wrist. How will the nurse interpret this finding?
- A. The patient is allergic to certain medications or foods.
- B. The patient has do not resuscitate preferences.
- C. The patient has a high risk for falls.
- D. The patient is at risk for seizures.
Correct Answer: B
Rationale: The correct answer is B: The patient has do not resuscitate preferences. A purple wristband typically signifies that a patient has chosen do not resuscitate (DNR) status. This means that the patient has made a decision to not receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. This information is crucial for healthcare providers to know and respect the patient's wishes. The other choices are incorrect because a purple wristband does not indicate allergies (A), fall risk (C), or seizure risk (D). It is essential for the nurse to be aware of the significance of different colored wristbands to provide appropriate care and respect the patient's autonomy.
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An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient?
- A. Positions patient's buttocks close to the front of wheelchair seat
- B. Backs wheelchair into elevator
- C. leading with large rear wheels first
- D. Places locked wheelchair on same side of bed as patient's weaker side
- E. Unlocks wheelchair for easy maneuverability when patient is transferring
Correct Answer: B
Rationale: The correct answer is B because backing the wheelchair into the elevator allows the nurse to maintain visual contact with the patient and ensures a safe exit from the elevator. This also prevents any potential accidents or injuries that may occur if the wheelchair is pushed forward into the elevator, where the nurse may not be able to see obstacles or other individuals. Positioning the patient's buttocks close to the front of the wheelchair seat (choice A) may cause discomfort and pressure ulcers. Leading with large rear wheels first (choice C) can be dangerous as it may cause the wheelchair to tip over. Placing a locked wheelchair on the same side of the bed as the patient's weaker side (choice D) restricts the patient's ability to access the wheelchair. Unlocking the wheelchair for easy maneuverability (choice E) is important but not directly related to safe transport in this context.
The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family? (Select all that apply.)
- A. Demonstrate how to restrain the patient in the event of a seizure.
- B. Instruct the family to move the patient to a bed during a seizure.
- C. Teach the family how to insert a tongue depressor during the seizure.
- D. Discuss with the family steps to take if the seizure does not discontinue.
- E. Instruct the family to reorient and reassure the patient after consciousness is regained.
Correct Answer: D,E
Rationale: The correct answers are D and E. D is important as it addresses the need for the family to know what to do if the seizure does not stop, such as calling emergency services. E is crucial as it focuses on the post-seizure care, which includes reorienting and reassuring the patient. A is incorrect as restraining a patient during a seizure can be harmful. B is incorrect as moving the patient during a seizure can lead to injury. C is incorrect as inserting a tongue depressor can also be harmful and is not recommended during a seizure.
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: Correct Answer: B - The patient wears the red nonslip footwear.
Rationale: The yellow armband typically signifies fall risk in healthcare settings. By wearing red nonslip footwear, the patient demonstrates understanding of the fall risk and the importance of preventing falls. This indicates a good comprehension of the armband's purpose and the need for safety precautions.
Other Choices:
A: The patient removing the armband to bathe does not demonstrate understanding of its significance in preventing falls.
C: Insisting on taking a 'water' pill in the evening is unrelated to the purpose of the yellow armband.
D: Asking about a new medicine when allergic to penicillin does not show understanding of the armband's purpose.
A home health nurse assesses a home after the birth of an infant. A toddler also lives in the home. Which finding requires follow-up?
- A. Plastic grocery bags stored under the counter.
- B. Electric outlets are covered.
- C. No bumper pads in crib.
- D. Crib slats are 5 cm apart.
Correct Answer: A
Rationale: The correct answer is A because plastic grocery bags stored under the counter pose a suffocation hazard for the toddler. This finding requires follow-up to ensure the bags are kept out of reach. Choices B, C, and D are not immediate safety concerns. Electric outlets covered prevent electrical hazards, no bumper pads in the crib reduce the risk of Sudden Infant Death Syndrome, and crib slats being 5 cm apart meet safety standards.
A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session?
- A. Run wires under the carpet.
- B. Disconnect items before cleaning.
- C. Grasp the cord when unplugging items.
- D. Use masking tape to secure cords to the floor.
Correct Answer: B
Rationale: The correct answer is B: Disconnect items before cleaning. This is important to prevent electrical shock as it ensures that there is no power running through the appliances while they are being cleaned. Running wires under the carpet (A) can lead to overheating and potential fire hazards. Grasping the cord when unplugging items (C) is unsafe as it can cause damage to the cord and increase the risk of electrical shock. Using masking tape to secure cords to the floor (D) is not recommended as it can lead to tripping hazards and damage to the cords.