Nokea
The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.)
- A. Close all doors.
- B. Note evacuation routes.
- C. Note oxygen shut-offs.
- D. Move bedridden patients in their bed.
- E. Wait until the fire department arrives to act.
Correct Answer: A,B,C,D
Rationale: The correct actions for the nurse to take in this scenario are A, B, C, and D. Closing all doors helps contain the fire and smoke, protecting patients. Noting evacuation routes ensures a quick and safe exit strategy if needed. Identifying oxygen shut-offs prevents potential fuel for a fire. Moving bedridden patients in their bed is crucial for their safety and transportability. Waiting for the fire department (choice E) is not recommended as immediate action by the nurse is necessary to ensure patient safety.
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The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?
- A. Are you able to hear the tornado sirens in your area?
- B. Are you able to read your favorite book?
- C. Are you able to taste spices like before?
- D. Are you able to open a jar of pickles?
Correct Answer: A
Rationale: The correct answer is A: "Are you able to hear the tornado sirens in your area?" This is the most important question because hearing loss is a common age-related physiological change that can affect safety, especially during emergencies like tornadoes. The ability to hear warning signals is crucial for timely response and ensuring the safety of older adults. Choices B, C, and D are not as critical for safety concerns compared to the ability to hear warning sirens. Older adults may use aids for reading, cooking, or opening jars, but compromised hearing can directly impact their ability to respond to emergencies effectively.
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 action of repeatedly removing the nasogastric tube poses a direct risk to their health and safety. This behavior indicates a lack of understanding or ability to comprehend the importance of the tube in their care. Restraints may be necessary to prevent harm in this situation. Refusing to call for help, confusion about time, and insomnia do not directly indicate a need for restraints. These behaviors may require further assessment and interventions, but they do not pose an immediate threat to the patient's well-being like removing a necessary medical device.
A patient has an ankle restraint applied. Upon assessment
- A. the nurse finds the toes a light blue color. Which action will the nurse take next?
- B. Remove the restraint.
- C. Place a blanket over the feet.
- D. Do a complete head-to-toe neurologic assessment.
- E. Take the patient's vital signs.
Correct Answer: A
Rationale: The correct answer is A because a light blue color in the toes indicates poor circulation due to the restraint. The nurse should assess for tissue damage and remove the restraint immediately to restore circulation. Removing the restraint is the priority to prevent further complications. Choice B is incorrect as it doesn't address the circulatory issue. Choices C, D, and E are not the immediate concern and can be addressed after addressing the circulation problem.
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.
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.