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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 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.
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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: The correct answers are A, C, D.
A: Smoking in bed poses a significant fire hazard due to the risk of falling asleep while smoking, leading to potential ignition of bed linens.
C: Using an old space heater may increase the risk of malfunction and fire hazards, as older models may not have modern safety features.
D: Using the RACE method for fire extinguisher use (Rescue, Alarm, Contain, Extinguish) is incorrect; the correct method is PASS (Pull, Aim, Squeeze, Sweep).
B, E: Leaving candles burning and having fire extinguishers accessible are good fire safety practices.
In summary, choices A, C, and D warrant intervention due to the increased risk of fire hazards, while choices B and E demonstrate good fire safety habits.
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.
A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?
- A. 55 years old
- B. 20/20 vision
- C. Urinary continence
- D. Orthostatic hypotension
Correct Answer: D
Rationale: The correct answer is D: Orthostatic hypotension. This finding indicates a drop in blood pressure upon standing, which can lead to dizziness and falls. A 55-year-old age (choice A) does not inherently indicate fall risk. 20/20 vision (choice B) does not directly correlate with fall risk. Urinary continence (choice C) is not a significant fall risk factor. The presence of orthostatic hypotension (choice D) is a clear indicator of potential falls due to the risk of dizziness and loss of balance.
The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring?
- A. Tile floors, cold food, scratchy linen, and noisy alarms.
- B. Dirty floors, hallways blocked, medication room locked, and alarms set.
- C. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach.
- D. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly.
Correct Answer: D
Rationale: The correct answer is D because wet floors unmarked pose slip hazards, patient pinching fingers in the door indicates lack of safety measures, failure to use a lift for patient increases risk of injury, and alarms not functioning properly can lead to delayed response. Choice A includes minor inconveniences but not significant safety risks. Choice B focuses on facility maintenance rather than direct patient safety risks. Choice C mentions minor issues like empty ice machine and unlocked supply cabinet that do not directly impact patient safety.
The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?
- A. Increased aggressiveness and blood spots on clothing may indicate substance abuse.
- B. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing.
- C. Adolescents need information about the effects of uncoordination on accidents.
- D. Adolescents need to be reminded to use seat belts primarily on long trips.
Correct Answer: A
Rationale: The correct answer is A because increased aggressiveness and blood spots on clothing are potential signs of substance abuse in adolescents. Aggressiveness and physical changes can indicate underlying issues like substance abuse, which is crucial for parents to recognize for intervention. B is incorrect because aggressiveness alone is not a definitive clue for substance abuse. C is incorrect as it focuses on uncoordination rather than specific signs of substance abuse. D is incorrect as it is a general safety reminder and not specific to substance abuse indicators.