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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 homeless adult patient presents to the emergency department with vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
- A. Respiratory rate
- B. Temperature
- C. Apical pulse
- D. Blood pressure
Correct Answer: B
Rationale: The correct answer is B: Temperature. A temperature of 94.8°F indicates hypothermia, which can be life-threatening and requires immediate attention to prevent further complications. Hypothermia can lead to decreased heart rate and blood pressure, affecting overall perfusion. Addressing the temperature first is crucial to prevent further deterioration. The other vital signs are within normal range and may not pose an immediate threat to the patient's life.
The patient is confused
- A. trying to get out of bed
- B. and pulling at the IV tubing. Which nursing diagnosis will the nurse add to the care plan?
- C. Impaired home maintenance
- D. Deficient knowledge
- E. Risk for poisoning
- F. Risk for injury
Correct Answer: D
Rationale: The correct answer is D: Deficient knowledge. The patient's confusion and behavior suggest a lack of understanding regarding the importance of staying in bed and not pulling at the IV tubing. By selecting this nursing diagnosis, the nurse can address the patient's cognitive deficits and provide education to prevent potential harm. Choice A is incorrect as it describes a behavior related to confusion, not a nursing diagnosis. Choice B focuses on the patient's actions rather than the underlying issue of knowledge deficit. Choices C, E, and F are not directly related to the patient's confusion and do not address the root cause of the behavior.
The nurse is performing the “Timed Get Up and Go (TUG)†assessment. Which actions will the nurse take? (Select all that apply.)
- A. Ranks a patient as high risk for falls after patient takes 18 seconds to complete
- B. Teaches patient to rise from straight back chair using arms for support
- C. Instructs the patient to walk 10 feet as quickly and safely as possible
- D. Observes for unsteadiness in patient's gait
- E. Begins counting after the instructions
- F. Allows the patient a practice trial.
Correct Answer: C, D, F
Rationale: The correct answers are C, D, and F.
C: Instructing the patient to walk 10 feet quickly and safely is a key step in the TUG assessment to evaluate mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is crucial to assess balance and risk of falls during the TUG assessment.
F: Allowing the patient a practice trial helps ensure that they understand the instructions and can perform the task accurately during the actual assessment.
These actions are essential for a comprehensive and accurate evaluation of the patient's mobility and fall risk during the Timed Get Up and Go assessment.
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.
During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
- A. The patient is oriented.
- B. The patient takes a hypnotic.
- C. The patient walks 2 miles a day.
- D. The patient recently became widowed.
Correct Answer: B
Rationale: The correct answer is B: The patient takes a hypnotic. Patients taking hypnotic medications are at an increased risk for falls due to the sedative effects of these drugs, causing dizziness, impaired balance, and confusion. This increases the likelihood of accidents and falls.
Incorrect Choices:
A: The patient is oriented. Being oriented does not necessarily indicate a decreased risk for falls.
C: The patient walks 2 miles a day. Regular exercise is beneficial for overall health but does not directly correlate with fall risk.
D: The patient recently became widowed. While emotional distress can affect a person's well-being, it does not directly indicate an increased risk for falls.