Yoost EAQ Chapter 25
The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: 1 Place a bed alarm device on the bed. 2 Place the patient in a belt restraint. 3 Provide one-on-one observation of the patient. 4 Apply wrist restraints.
1 Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently. STUDY TIP: Be clear on the requirements to be met before using restraints. For the situation in this question, alternatives had not yet been implemented.
The nurse educator is discussing safety measures to prevent injuries in teenagers with a group of parents. What is the most important topic that the nurse should discuss in this session? 1 Choking hazards 2 Motor vehicle accidents 3 Occupational hazards 4 Physiologic changes
2 Motor vehicle accidents are frequent. Safety courses, driver's education, use of seatbelts, and avoidance of cell phone use, texting, and other distractions while driving are important. Choking hazards are more frequent in infants, toddlers, preschoolers and the aged. Occupational hazards are common in adults who are exposed to dangers on the job. Physiologic changes occur in body systems with aging; these changes put older adults at risk for falls. STUDY TIP: Take a look at your car insurance bill. Call the insurance company and ask what the cost would be (for the same vehicle and location) if you were 16 years old versus 26 years old. This exercise will help you to remember that the risk for motor vehicle accidents is high in teens.
In which position should the nurse place an infant to prevent sudden infant death syndrome? 1 Prone position 2 Supine position 3 Left lateral position 4 Head tilt-up position
2 The nurse should place the infant in the supine position to prevent sudden infant death syndrome. In the prone position, there is a high risk of aspiration and suffocation. Therefore, this position is not helpful to prevent sudden infant death syndrome. The left lateral position is recommended for premature infants who have gastroesophageal reflux. An abnormal head posture such as the head tilt-up position may cause the facial bones to grow abnormally, leading to facial asymmetry. STUDY TIP: One of the programs used to teach new parents to place newborns in the supine position was the "Back to Sleep" program. It reminded parents to place an infant on his/her back in the crib.
The nurse is reviewing the laboratory reports of a patient in the intensive care unit who has developed aspiration pneumonia. Which equipment misplacement does the nurse identify as the reason for the pneumonia? 1 Foley catheter 2 Infusion pump 3 Nasogastric tube 4 Nephrostomy tube
3 A nasogastric tube is a narrow tube that is used to feed the patient or to aspirate the stomach contents. It is passed into the stomach via the nose. If the tube is misplaced into the lungs, it will lead to aspiration pneumonia. A Foley catheter is a thin, flexible, sterile tube that is inserted into the bladder to empty it. The use of a Foley catheter may lead to urinary tract infections if it is contaminated during insertion. Infusion pumps are used to administer saline solution, medications, and other fluids; misplacement of these pumps would result in tissue injury at the site of administration. A nephrostomy tube is used to drain urine from the kidneys into a bag outside the body. The misplacement of the nephrostomy tubes may cause trauma to the renal tubules. Test-Taking Tip: Notice the body system affected in the question. In this case, it is the respiratory system. Now consider the choices with that system in mind; only one choice had potential contact with the respiratory system.
A nurse works in a psychiatric unit. The nurse understands that the use of restraints may be useful for ensuring patient's safety. A patient has been advised bed rest. The patient often becomes anxious and moves out of bed by removing the intravenous lines. When planning the use of chemical restraints for this patient, which one should the nurse anticipate the health care provider to order? 1 Protective helmet 2 A mechanical device 3 Anxiolytic medicines 4 Immobilizing equipment
3 Anxiolytic medicines, which are not a part of the patient's regular prescription, can be used as chemical restraints. These medications help to manage the patient's behavior by making them calm and inducing sleep. A protective helmet only allows the patient to perform activities without the risk of physical injury. It does not prevent other risks such as the risk associated with removal of the IV line. A mechanical device and immobilizing equipment are used as physical restraint. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. For this question, you can eliminate all three incorrect answers because they are not chemical restraints.
A patient using a charcoal grill inside the garage presents to the emergency room with dizziness, drowsiness, and nausea. These assessment findings would be consistent with which type of poisoning? 1 Lead poisoning 2 Antifreeze poisoning 3 Ammonia poisoning 4 Carbon monoxide poisoning
4 Carbon monoxide is a colorless, odorless gas that can cause sudden illness and even death and can build up when a charcoal grill is used inside a garage or basement. The symptoms of carbon monoxide poisoning are unexplained headache, dizziness, drowsiness, and nausea. Lead exposure can result in irreversible consequences to the nervous system and usually occurs in children ages 1-5 due to exposure to lead-based paint in older buildings and in toys. Ammonia poisoning can occur from common household chemicals like cleansers. Antifreeze is a toxin that can poison the body but does not result from a charcoal grill inside the garage.
A couple intends to take their 5-year-old child for a long ride in a car. What advice does the nurse provide to this couple? 1 Advise the couple that the child can ride in the front seat for short rides, but not long rides. 2 Discourage taking the child for a long ride as this may disrupt the child's usual routine. 3 Advise the couple to leave the child unbuckled, but sitting on an adult's lap if a car seat is unavailable. 4 Advise the couple of the need for an appropriate car seat for this child.
4 Children less than 8 years of age or those who weigh less than 80 pounds should use an appropriate car seat as specified by the manufacturer. If there is a car accident, the child is likely to have fewer injuries when seated in the back seat than the front seat, regardless of the length of the drive. It is inappropriate to advise the parents to avoid taking children for long rides. Children should be taken for family rides with appropriate safety measures. In cases of a sudden stop of the car or a car crash, the child is susceptible to severe head injuries if left unrestrained, therefore a child should never sit on an adult's lap rather than being properly buckled into a car seat.
A patient who works in a coal mine is referred to an occupational health center. Which services are provided to ensure the safety of the patient? 1 It includes coverage to pay the bills of patients who get ill or injured. 2 It provides health promotion services through a school curriculum. 3 It provides services to older patients or those unable to leave their homes. 4 It provides services for health promotion, and accident and illness prevention.
4 Occupational care centers provide services for health promotion and accident and illness prevention in the workplace. Health insurance pays the bills of a patient who gets ill or injured. School health is a program that includes health promotion through the school curriculum. Block and parish nursing provides services to older patients or those unable to leave their homes.
A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? 1 Begin cardiopulmonary respiration. 2 Restrain the child to prevent injury. 3 Place a tongue blade over the tongue to prevent aspiration. 4 Clear the area around the child to protect the child from injury.
4 Once a seizure begins, you need to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth. See the skills in the chapter for more information.
There is a fire in a hospital. Which is the first priority action of the nurse? 1 Activating the fire alarms 2 Confining the fire 3 Extinguishing the fire 4 Rescuing patients in immediate danger
4 The nurse should use the mnemonic RACE to set priorities in case of a fire. When there is a fire in a hospital, the first and the most important intervention of the nurse would be to Rescue and remove all the patients who are in immediate danger. After those patients are removed, the nurse should Activate the fire alarm so that other patients and staff will know of the fire danger. After this the nurse should Confine the fire by closing all doors and windows and turning off oxygen and electrical equipment. Finally, the nurse may attempt to Extinguish the fire with the use of an appropriate fire extinguisher. Test-Taking Tip: Did you notice the acronym "RACE" in the choices? When the textbook has explained (or your instructor has taught) an acronym, look for it in the choices. It may have been shuffled out of order, but recognizing that it is there will be a huge clue for the correct response.
A patient gets poison on the skin. What is the priority nursing intervention? 1 Administer an oral antihistamine tablet 2 Apply cool compresses to the contaminated area 3 Take the patient outside for fresh air as soon as possible 4 Remove clothing that was in contact with the chemical
4 While caring for a patient who has been exposed to poison on the skin, the nurse should first remove the clothing that was in contact with the poison and rinse the skin with water for at least 15 minutes. If itching or inflammation still persists, an antihistamine tablet can be administered to the patient on the primary health care provider's prescription. Using cool compresses is not appropriate at this time. Taking the patient outside for fresh air occurs if the poison has been inhaled. STUDY TIP: Try rinsing your hand or forearm under running water for 15 minutes to help you remember this point. It seems like a really long time, but removing contact with the poison and rinsing are the first priority!
A nurse is caring for an older adult in his home. The nurse is concerned about the risk of injury. Following an assessment, the nurse finds that the patient has visual impairment. Which actions should the nurse perform to reduce the risk of injury in this patient? Select all that apply. A Keep the home well lit. B Keep the rooms ventilated. C Keep clean eye glasses at hand. D Teach range of motion exercises. E Familiarize the patient with the surroundings.
A, C, E Keeping the home well lit will help the patient see the objects without trouble. Clean and protected eye glasses at hand will help the patient see clearly. Familiarizing the patient with the surroundings will improve the patient's orientation to the objects and furniture at home. Keeping the rooms ventilated may not help the patient in reducing risk of injury. Range of motion exercises may be performed in patients with altered mobility.