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Questions and Answers
A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?
A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?
The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient’s health care needs?
The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient’s health care needs?
What statement by the nurse demonstrates an understanding of food safety to be provided for a patient living alone?
What statement by the nurse demonstrates an understanding of food safety to be provided for a patient living alone?
An adult patient presents to the emergency department and is treated for hypothermia. What risk factor should the patient be assessed for?
An adult patient presents to the emergency department and is treated for hypothermia. What risk factor should the patient be assessed for?
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A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?
A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?
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The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event?
The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event?
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When the nurse discovers a patient on the floor, the patient states, “I fell out of bed.”The nurse assesses the patient and then places the patient back in bed. Which action should the nurse take next?
When the nurse discovers a patient on the floor, the patient states, “I fell out of bed.”The nurse assesses the patient and then places the patient back in bed. Which action should the nurse take next?
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When making rounds the nurse observes a purple wristband on a patient’s wrist. What information about the patient does this provide the nurse?
When making rounds the nurse observes a purple wristband on a patient’s wrist. What information about the patient does this provide the nurse?
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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 nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?
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The nurse is assessing a patient for possible lead poisoning. Which patient is the nurse most likely assessing?
The nurse is assessing a patient for possible lead poisoning. Which patient is the nurse most likely assessing?
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A nurse is teaching a community group of school-aged parents about safety. The proper fitting of which safety item is most important for the nurse to include in the teaching session?
A nurse is teaching a community group of school-aged parents about safety. The proper fitting of which safety item is most important for the nurse to include in the teaching session?
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The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?
The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?
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The nurse is discussing threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?
The nurse is discussing threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?
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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?
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?
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The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the temporary need for a restraint?
The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the temporary need for a restraint?
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The nurse is admitting an older adult to the surgical unit. What intervention is necessary when determining the safe use of side rails for this patient?
The nurse is admitting an older adult to the surgical unit. What intervention is necessary when determining the safe use of side rails for this patient?
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The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take to minimize the patient’s risk for injury?
The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take to minimize the patient’s risk for injury?
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The nurse is monitoring for risks for injury identified in the health care environment. Which finding will alert the nurse that these safety risks are occurring?
The nurse is monitoring for risks for injury identified in the health care environment. Which finding will alert the nurse that these safety risks are occurring?
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Which activity will increase the need for the nurse to monitor for equipment-related accidents?
Which activity will increase the need for the nurse to monitor for equipment-related accidents?
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A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?
A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?
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A nurse is attempting to minimize the risk of future infection for a post-surgical patient about to be discharged. Which technique will the nurse teach the patient to best achieve this goal?
A nurse is attempting to minimize the risk of future infection for a post-surgical patient about to be discharged. Which technique will the nurse teach the patient to best achieve this goal?
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A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?
A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?
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During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
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A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
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A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?
A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?
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The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?
The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?
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The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?
The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?
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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 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?
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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?
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?
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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?
- Pull the alarm.
- Remove the patient.
- Use the fire extinguisher.
- Close doors and windows.
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?
- Pull the alarm.
- Remove the patient.
- Use the fire extinguisher.
- Close doors and windows.
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The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
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A home health nurse is assessing a family’s home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up?
A home health nurse is assessing a family’s home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up?
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Which patient will the nurse see first?
Which patient will the nurse see first?
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A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session?
A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session?
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The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action?
The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action?
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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?
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?
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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 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.)
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The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.)
The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.)
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A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.)
A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.)
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The nurse is performing the "Timed Get Up and Go (TUG)" assessment. Which mobility issues will this test measure? (Select all that apply.)
The nurse is performing the "Timed Get Up and Go (TUG)" assessment. Which mobility issues will this test measure? (Select all that apply.)
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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.)
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.)
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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.)
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.)
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The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient’s medical record to provide safe care? (Select all that apply.)
The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient’s medical record to provide safe care? (Select all that apply.)
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Study Notes
Home Health and Patient Safety
- A home health nurse assesses safety during home visits, prioritizing patient comments indicating risk.
- Older-adult patients with specific symptoms like nausea, vomiting, and diarrhea need careful evaluation for social service collaboration to address healthcare needs.
- Essential for promoting food safety for individuals living alone includes proper food storage and preparation guidelines.
Emergency and Acute Care
- Evaluate adults presenting with hypothermia for underlying issues such as potential alcohol use or lack of heat source.
- Teaching proper wound care involves emphasizing hand hygiene to prevent pathogen transmission.
Incident Reports and Safety Protocols
- Identification of Never Events like wrong-site surgery or patient falls must be reported immediately.
- If a patient falls and states they fell out of bed, follow-up assessment and proper placement in bed are crucial for safety.
Patient Identification and Risk Assessment
- A purple wristband worn by a patient typically indicates a Do Not Resuscitate (DNR) order.
- Patients with a history of falls, confusion, or medication changes are at increased risk for falls; thorough assessment is necessary.
Lead Poisoning and Safeguarding
- Assess children, particularly those in older homes or with known exposure risks, for lead poisoning.
- Proper fitting of safety helmets is crucial when educating parents about child safety.
Educational Initiatives
- Informing parents of adolescents includes discussing risks associated with social behaviors and accidents.
- Highlighting age-related physiological changes impacting safety among older adults is essential for targeted interventions.
Restraint Use and Safety
- Restraint use may require evaluation if a patient exhibits unsafe behaviors, with documentation and clear rationale needed.
- Determining safe side rail use for older patients requires careful assessment of mobility and fall risk.
Equipment and Patient Monitoring
- Continuous monitoring for alteration in patient status (e.g., confusion or IV manipulation) minimizes injury risks.
- Focus on environmental safety, including hazards related to equipment use, is vital.
Fire Safety Protocols
- In case of a fire, following the RACE protocol (Rescue, Alarm, Contain, Extinguish) is crucial to ensure patient safety.
- Address potential accidental poisoning by clarifying safety measures with caregivers, particularly regarding child safety.
Home and Electrical Safety
- Home health assessments post-infant birth must identify safety concerns like electrical outlets being accessible to toddlers.
- Teach families about preventing electrical shocks through proper wiring and outlet covers.
Documentation and Legal Compliance
- Legally binding and appropriate restraints are documented considering patient consent and observation for any adverse effects.
- The "Timed Get Up and Go (TUG)" test helps assess mobility issues important for fall risk assessment.
Emergency Preparedness
- In emergencies, a swift plan is developed to ensure patient safety against potential fires or evacuations.
- Essential documentation during restraint use must include key observations, patient behavior, and interventions provided.
Patient Education and Resource Management
- Frequent education on seizure management for families, especially post-injury, aids in promoting safety and understanding.
- Use of color-coded wristbands improves patient identification for specific medical needs among hospital populations.
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Description
A home health nurse is conducting a home assessment to identify potential safety hazards and provide guidance to the patient. What would trigger the nurse to take further action?
