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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.
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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 to address the patient's health care needs?
- 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. The priority concern that requires collaboration with social services is the electricity being turned off 3 days ago. This is crucial because without electricity, the patient's access to essential medical devices, such as a refrigerator for storing medications or a nebulizer for breathing treatments, is compromised. Social services can help address this issue by connecting the patient with resources for utility assistance or temporary housing.
Choice B is incorrect because access to county water supply is not directly related to the patient's immediate health care needs in this scenario. Choice C is also incorrect as the son and family moving in is not a priority concern requiring collaboration with social services. Choice D is not a priority concern either, as the lack of a microwave oven does not impact the patient's health care needs significantly.
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.
A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?
- A. Risk for injury: Check on patient every 15 minutes.
- B. Risk for suffocation: Place 'Oxygen in Use' sign on door.
- C. Disturbed body image: Encourage patient to express concerns about body.
- D. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.
Correct Answer: A
Rationale: The correct answer is A: Risk for injury: Check on patient every 15 minutes.
Rationale:
1. Priority: Safety of the patient is the top priority, as the patient is at risk for injury due to attempts to remove essential medical devices.
2. Regular monitoring: Checking on the patient every 15 minutes allows for timely intervention if the patient attempts to remove the oxygen cannula or urinary catheter.
3. Prevention of harm: By checking frequently, nurses can prevent potential harm such as hypoxia or catheter-related complications.
4. Immediate action: This intervention addresses the immediate safety concern and ensures the patient's well-being.
Incorrect choices:
B: Risk for suffocation: Placing a sign does not directly address the patient's behavior.
C: Disturbed body image: Patient's behavior is not related to body image concerns.
D: Deficient knowledge: Explaining the purpose does not address the immediate safety risk.
A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident?
- A. Pathogenic asepsis
- B. Medical asepsis
- C. Surgical asepsis
- D. Clean asepsis
Correct Answer: C
Rationale: The correct answer is C: Surgical asepsis. This technique involves creating and maintaining a sterile field to prevent contamination during invasive procedures like catheter insertion. The nurse will use sterile gloves, drapes, and equipment to minimize the risk of infection. Pathogenic asepsis (A) focuses on removing or destroying pathogens but may not ensure sterility. Medical asepsis (B) aims to reduce the number of pathogens but does not achieve a sterile environment. Clean asepsis (D) involves cleanliness but not the level of sterility required for invasive procedures.
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.