36 hours after having surgery, a patient has slightly elevated body temperate and malaise as well as pain and redness at the surgical site. which intervention is most important to include in this patients nursing care plan?

document the findings and continue to monitor the patient EXTRA INFO: this patient is in the inflammatory phase meaning its a generalized body response of their high temp and malaise

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage which statements accurately describe a characteristic of wound drainage? SELECT ALL THAT APPLY(a)serous drainage is composed of the clear portion of the blood and serous membranes(b) sanguineous drainage is composed of a large # of red blood cells and looks like blood(c) bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding(d) purulent drainage is composed of white blood cells, dead tissue, and bacteria(e) purulent drainage is thin cloudy and watery and may have a musty or foul odor (f) serosanguineous drainage can be dark yellow or green depending on the causative organism

(1)serous drainage is composed of the clear portion of the blood and serous membranes(2) sanguineous drainage is composed of a large # of red blood cells and looks like blood(3) bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding(4) purulent drainage is composed of white blood cells, dead tissue, and bacteriaEXTRA INFO: serious drainage is clear and wateryserosanguineous drainage is a mixture of serum and red blood cells so it looks pink!

A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. inspection reveals a gaping open wound with tissue building outward. In which order should the nurse perform the following interventions?

(1) place the patient in low fowlers position (prevents further damage) THEN(2) cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution THEN(3) notify the health care provider of the situation (will likely need surgery)

A patient was in an automobile accident and received a wound across the nose and cheek. after surgery to repair the wound, the patient says, " I am so ugly now". based on this statement, which nursing diagnosis would be more appropriate?

Disturbed body image

A patient is admitted with a non healing surgical wound. which nursing action is most effective in preventing a wound infection?

Preforming careful hand hygiene (most important)

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply.a. Hemostasis occurs immediately after the initial injury.b. A liquid called exudate is formed during the proliferation phasec. White blood cells move to the wound in the inflammatory phase.d. Granulation tissue forms in the inflammatory phase.e. During the inflammatory phase, the patient has generalized body response.f. A scar forms during the proliferation phase.

A. hemostasis occurs immediately after the initial injuryC. white blood cells move to the wound in the inflammatory phaseE. during the inflammatory phase the patient has generalized body response

The nurses assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply a. enhanced healing due to the presence of sugars and proteinsb. delayed healing due to dead tissue present in the woundc. decreased effectiveness of antibiotics against the bacteriad. impaired skin integrity due to over hydration of the cells of the wounde. delayed healing due to cells dehydrating and dyingf. decreased effectiveness of the patients normal immune process

c. decreased effectiveness of antibiotics against the bacteria f. decreased effectiveness of the patients normal immune processEXTRA INFO: necrosis is dead tissue delays healing.impaired skin integrity due to over hydration are related to urine and fecal incontinence .desiccation is the process of cells drying up

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply.a. Use standard precautions or transmission-based precautions when indicated.b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution.c. Clean the wound in full or half circles beginning on the outside and working toward the center.d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area.e. Clean to at least one inch beyond the end of the new dressing if one is being applied.f. Clean to at least three inches beyond the wound if a new dressing is not being applied.

a. Use standard precautions or transmission-based precautions when indicated.b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution.e. Clean to at least one inch beyond the end of the new dressing if one is being applied. (clean 2 inches beyond if dressing is not applied NOT 3)EXTRA INFO : clean the wound in full or half circles beginning with the center then working towards outside clean from cleanest to dirtiest

A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). which assessment findings indicate a high risk for pressure injury development of this patient? SELECT ALL THAT APPLYa. the patient takes time to think about responses to questionsb. the patient is 86 years oldc. the patient reports inability to control urined. the patient is scheduled for a hip arthroplasty e. lab findings include BUN 12 (normal 8-23) and creatinine 0.9 (female normal 0.61 to 1mg)f. the patient reports increased pain in right hip when repositioning in bed or chair

b. the patient is 86 years oldc. the patient reports inability to control urined. the patient is scheduled for a hip arthroplasty f. the patient reports increased pain in right hip when repositioning in bed or chair

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation?a. I can expect to have ore discomfort in the area where the cold is appliedb. I should expect more drainage from the incision after the ice has been in placec. I should see less swelling and redness with the cold treatment d. my incision may bleed more when the ice is first applied

c. I should see less swelling and redness with the cold treatment

A nurse is providing patient teaching regarding the use of negative pressure wound therapy. which explanation provides the most accurate information to the patient?a. the early is used to collect excess blood loss and prevent the formation of a scabb. the therapy will prevent infection ensuring that the wound heals with less scar tissuec. the therapy provides a moist environment and stimulates blood flow to the woundd. the therapy irrigates the wound to keep it free from debris and excess wound fluid

c. the therapy provides a moist environment and stimulates blood flow to the woundEXTRA INFO: negative pressure wound therapy promotes wound healing and wound closure through the application of negative pressure on the wound bed, reduction in bacteria in the wounds and the removal of excess fluid

After an initial skin assessment the nurse documents the presence of a reddened area that has blistered. according to recognized staging systems this pressure injury would be classified as?

stage 2

The nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound?a. Irrigate the wound.b. Provide gentle cleansing of the wound. c. Débride the wound.d. Change the dressing frequently.

b. provide gentle cleaning of the woundEXTRA INFO: red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds at this stage need protection to cleanse yellow wounds nurses irrigate the woundIf eschar is found in black wounds it requires debridement

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. which action accurately describes a priority intervention in preventing a patient from developing a pressure injury?a. keeping the head of the bed elevated as often as possibleb. massaging over bony prominences c. repositioning bed bound patients every 4 hoursd. using a mild cleaning agent when cleaning the skin

d. using a mild cleaning agent when cleaning the skinEXTRA INFO: shearing can occur with prolonged head of the bed being elevated bony prominences should NOT be massagedpatients should be repositioned every 2 hours

A nurse measuring the depth of a patients puncture wound. which technique is recommended?a. moisten a sterile. flexible applicators with saline and insert it gently into the wound at a 90 degree angle with the tip downb. draw the shape of the wound and describe how deep it appears in centimetersc. gently insert a sterile applicators into the wound and move it in a clock wise direction d. insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker

a. moisten a sterile. flexible applicators with saline and insert it gently into the wound at a 90 degree angle with the tip down

A nurse is preparing an exercise program for a patient who has COPD (chronic obstructive pulmonary disease). Which instruction should the nurse include in a teaching plan for this patient?SELECT ALL THAT APPLYa. instruct the patients to avoid sudden position changes that may cause dizzinessb. recommend that the patient restrict fluid until after exercising is finishedc. instruct the patient to push a little further beyond fatigue in each session d. instruct the patient to avoid exercising in very cold or very hot temperaturese. encourage the patient to modify exercise if weak or illf. recommend that the patient consume a high-carb low protein diet

a. instruct the patients to avoid sudden position changes that may cause dizzinessd. instruct the patient to avoid exercising in very cold or very hot temperaturesEXTRA INFO: provide adequate hydration, do not push patient to exhaustion, consume high protein diet

A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session the patient complains that she is too tired to go on. What would be priority nursing action for this patient?SELECT ALL THAT APPLYa. stop performing the exercisesb. decrease the number of repetition performedc. reevaluate the nursing care pland. move to the patients other side to perform exercisese. encourage the patient to finish the exercises and then restf. assess the patient for other symptoms

a. stop performing the exercisesc. reevaluate the nursing care planf. assess the patient for other symptoms

A nurse is ambulating a patient for the first time following surgery for a knee replacement. shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place the nursing action sin the order in which the nurse should perform them to protect the patient

place feet wide apart with one foot in frontrock your pelvis out on the side nearest the patientgrasps the gain beltsupport the patient by pulling her weight backward against your bodygently slide her down your body toward the floor while protecting the headstay with patient and call for help

A nurse caring for patients in a pediatricians office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones?a. a 4 month old infant who is unable to roll overb. a 6 month old infant who is unable to hold his head up himselfc. an 11 month old infant who cannot walk unassistedd. an 18 month old toddler who cannot jump

b. a 6 month old infant who is unable to hold his head up himselfEXTRA INFO: by 5 months head control is achievedan infant usually rolls over 6-9 months by 15 months most toddlers walk by 2 years they can jump

A nurse caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side?a. have the patient extend his arms outward and cross his legs on top of a pillowb. stand at the side of the bed in which the patient will be turned while another nurse gently pushed the patient from the other side. c. have the patient cross his arms on his chest and place a pillow between his kneesd. place a cervical collar on the patients neck and gently roll him to the other side of the bed

c. have the patient cross his arms on his chest and place a pillow between his knees

A nurse is caring for a patient in a long term care facility who has had 2 urinary tract infections in the past year related to immobility. which finding would the nurse expect in this patient?a. improved renal blood supply to the kidneysb. urinary stasisc. decreased urinary calciumd. acidic urine formation

b. urinary stasis EXTRA INFO: immobility can have INCREASED levels of urinary calcium and alkaline urine

A nurse if caring for a patient who is hospitalized with pneumonia and is experiencing some difficulties breathing. the nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity?a. dorsal recumbent positonb. lateral positionc. fowlers position d. sims position

c. fowlers position

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. which instructions from the nurse are appropriate for this patient? SELECT ALL THAT APPLYa. do full body pushups in bed six to eight times dailyb. breathe in and out smoothly during quadricep drillsc. place the bed in the lowest portion or use a foot stool for danglingd. dangle on the side of the bed for 30-6o minutese. allow the nurse to bathe the patient completely to prevent fatiguef. perform quadriceps two to three times per hour, four to six times a day

b. breathe in and out smoothly during quadricep drillsc. place the bed in the lowest portion or use a foot stool for danglingf. perform quadriceps two to three times per hour, four to six times a dayEXTRA INFO: pushups are done 3-4 times a day dangling for 30-60 minutes is not safe

A nurse is caring for a patient who is on bed rest following a spinal injury. in which position would the nurse place the patients feet to prevent foot drop?a. supinationb. dorsiflexionc. hyperextension d. abduction

b. dorsiflexion

A nurse is instructing a patient who is recovering from stroke how to use a cane. which step would the nurse include in the teaching plan for this patient? a. support weight on stronger leg and cane and advance weaker foot forwardb. hold the cane in the same hand of the legs with the most severe deficitc. stand with as much weight distributed on the cane as possibled. do not use the cane to rise from a sitting position , this is unsafe

a. support weight on stronger leg and cane and advance weaker foot forward

A patient has a fractured left leg, which has been casted. Following teaching from the phsyical therapist for using crutches, the nurse reinforced which teaching point with the patient?a. use the axillae to bear body weightb. keep elbows close to the sides of the bodyc. when rising, extend the uninjured leg to prevent weight bearing d. to climb stairs, place weight on affected leg first

b. keep elbows close to the sides of the body

A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures?a. carefully assessing the patient care environmentb. using two nurses to lift a patient who cannot assistc. wearing a back belt to perform routine dutiesd. properly documenting the patient lift

a. carefully assessing the patient environmentso that the patient can be moved safely and effectively

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patients knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action?a. wait a few minutes and then continue the move to the chairb. call for assistance and continue the move with the help of another nursec. Lower the patient back to the side of the bed and pivot her back into bedd. have the patient sit down on the bed and dangle her feet before moving

c. Lower the patient back to the side of the bed and pivot her back into bed

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position?a. side-lyingb. fowlersc. simsd. prone

d. proneEXTRA INFO: pull of gravity on the trunk when the patient lies prone produced a marked lords or forward curvature of the spine

A Katz index of independence in ADL/s once point is awarded for?

independence in each of the following activities:bathingdressingtoiletingtranferringcontinencefeeding

A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patients personal hygiene?a. when the patient has his or her most recent bathb. the patients usual hygiene practices and preferencesc. where the bathing fits in the nurses scheduled. the time that is convenient for the patient care assistant

b. the patients usual hygiene practices and preferences

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care. SELECT ALL THAT APPLY.a. it promotes the patients sense of well beingb. it prevents the deterioration of the oral cavity.c. it contributes to decreased incidence of aspiration pneumoniad. it eliminates the need for flossinge. it decreases oropharyngeal secretionsf. it helps to compensate for an inadequate diet.

a. it promotes the patients sense of well beingb. it prevents the deterioration of the oral cavity.c. it contributes to decreased incidence of aspiration pneumoni

A nurse assisting with a patient bed bath observes that an older female adult has dry skin. the patient states that her skin is always itchy. Which nursing action would be the nurses best responsea. bathe the patient more frequently b. use an emollient on the dry skinc. massage the skin with alcohol d. discourage fluid intake

b. use an emollient on the dry skin

A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk?SELECT ALL THAT APPLYa. a patient who is taking antibiotics for chronic bronchitis b. a patient diagnoses with type 2 diabetesc. a patient who is obesed. a patient who has a nervous habit of biting his nails e. a patient diagnosed with prostate cancerf. A patient whose job involves frequent hand washing

b. a patient diagnoses with type 2 diabetesc. a patient who is obesed. a patient who has a nervous habit of biting his nailsf. A patient whose job involves frequent hand washing

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply.a. Compare bilateral parts for symmetry.b. Proceed in a toe-to-head systematic manner.c. Use standard terminology to report and record findings. d. Do not allow data from the nursing history to direct the assessment.e. Document only skin abnormalities on the patient record. f. Perform the appropriate skin assessment when risk factors are identified.

a. Compare bilateral parts for symmetry.c. Use standard terminology to report and record findings. f. Perform the appropriate skin assessment when risk factors are identified.

A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? SELECT ALL THAT APPLYa. wash the skin twice a day with a mild cleanser and warm waterb. use cosmetics liberally to cover black headsc. use emollients on the aread. squeeze blackheadse. keep hair off the face and wash hairy dailyf. avoid sun tanning booth exposure and use sunscreen

a. wash the skin twice a day with a mild cleanser and warm watere. keep hair off the face and wash hairy dailyf. avoid sun tanning booth exposure and use sunscreen

A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What would be the nurses next action?a. make a recommendation for the patient to see an oral surgeon b. report the condition to the primary care providerc. gently scrape the oral cavity with a tongue depressord. increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa

d. increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa

A nurse is removing rigid gas-permeable (RGP) contact lenses from the eyes of a patient who is unable to assist with removal. The nurse notices that one of the lenses is not centered over the cornea. What would be the nurses first action in this procedure?a. apply gentle pressure on the lower eyelid to center the lens prior to removing it.b. move the eyelids toward one another to cause the lends to slide out between the eyelidsc. do not attempt to remove the lens sit should only be removed by an eyecare specialistd. have the patient look forward, retract the lower lid and move the lens down on the sclera

a. apply gentle pressure on the lower eyelid to center the lens prior to removing it.

A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patients eyes? a. use hydrogen peroxide on a clean washcloth to wipe the eyesb. wipe the eye from the outer cants to the inner canthusc. position the patient on the opposite side of the eye to be cleaned.d. cleanse the eye using a different section of the cleaning cloth for each stroke until clean

d. cleanse the eye using a different section of the cleaning cloth for each stroke until clean

A nurse is providing foot care for patients in a long term facility. Which actions are recommended guidelines for this procedure?SELECT ALL THAT APPLYa. bathe the feet thoroughly in a mild soap and tepid water solutionb. soak the feet in warm water and bath oilc. dry feet thoroughly including the area in-between the toesd. use an alcohol rub if the feet are drye. use an antifungal foot powder if necessary to prevent fungal infectionsf. cut the toenails at the lateral corners when trimming the nail

a. bathe the feet thoroughly in a mild soap and tepid water solutionc. dry feet thoroughly including the area in-between the toese. use an antifungal foot powder if necessary to prevent fungal infectionsEXTRA INFO: the nurse should avoid soaking the feet, use moisturizer if skin is dry

A nurse is assisting a patient with dementia with bathing. Which guideline is recommended for this procedure?a. shift the focus of the interaction to the process of bathingb. wash the face and hair at the beginning of the bathc. consider using music to sooth anxiety and agitationd. do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar

c. consider using music to sooth anxiety and agitation EXTRA INFO: the nurse should wash the face and hair at the end of the bath

A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? SELECT ALL THAT APPLYa. for male and female patients, wash the groin area with a small amount of soap and water and rinseb. for a female patient spread the labia and move the washcloth from the anal area toward the pubic areac. for male and female patients always proceed from the most contaminated area to the least contaminated aread. for male and female patients, use a clean portion of the washcloth for each strokee. for a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outwardf. in an uncircumcised male patient. do not retract the foreskin (prepuce) while washing the penis

a. for male and female patients, wash the groin area with a small amount of soap and water and rinsed. for male and female patients, use a clean portion of the washcloth for each strokee. for a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outwardEXTRA INFO: always clean from least contaminated to mostfor females- move the wash cloth from the pubic area toward the anal arearetract the foreskin and clean for males

A nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure?a. add bath oil to the water to prevent dry skinb. allow for the patient to lock the door to guarantee privacyc. assist the patient in and out of the tub to prevent fallingd. keep the water temperature very warm because older adults chill easily

c. assist the patient in and out of the tub to prevent falling

A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patients gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action?a/ temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeveb. cut the gown with scissors to allow arm movementc. thread the bag and tubing through the gown sleeve, keeping the line intactd. temporarily disconnect the tubing from the IV container, threading it through the gown

c. thread the bag and tubing through the gown sleeve, keeping the line intactEXTRA INFO: cutting gown is only used in an emergencyopening an IV line can cause potential infection

A nurse if caring for a 25 year old male patient who is comatose following a head injury. The patient has several piece rings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this patients piercings?a. do not remove or wash the piercings without permission of the patientb. rinse the sites with warm water and remove crusts with a cotton swabc. Wash the item with alcohol and apply an antibiotic ointmentd. remove the jewelry and allow the sites to heal over

b. rinse the sites with warm water and remove crusts with a cotton swabEXTRA INFOuse liquid medicated cleanser to the areado not use alcohol, peroxide or ointments at the site or removing the piercings unless absolutely necessary (like when an MRI is ordered)

The nurse caring for patients in a long term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? SELECT ALL THAT APPLYa. a patient who is older than 50b. a patient who has already fallen twicec. a patient who is taking antibioticsd. a patient who experiences postural hypotension e. a patient who is experiencing nausea from chemo therapyf. a 70 yer old patient who is transferred to long term care

b. a patient who has already fallen twiced. a patient who experiences postural hypotensionf. a 70 yer old patient who is transferred to long term care

A school nurse is teaching parents about home safety and fires. What info would be accurate to include in the teaching plan? SELECT ALL THAT APPLYa. sixty percent of US fire deaths occur in the homeb. mot fatal fires occur when people are cookingc. mot people who die in fires die of smoke inhalation d. fire related injury and death have declined due to smoke alarmse. fires are more likely to occur in homes without electricity or gasf. fires are less likely to spread if bedroom doors are kept open when sleeping

c. mot people who die in fires die of smoke inhalationd. fire related injury and death have declined due to smoke alarmse. fires are more likely to occur in homes without electricity or gas

A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating?a. a toddler playing with his 9 year old brothers construction setb. a 4 year old eating yogurt for lunchc. an infant covered with a small blanket and asleep in the cribd. a 3 year old drinking a glass of juice

a. a toddler playing with his 9 year old brothers construction set

While discussing home safety with the nurse a patient admits that she always smoked a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient?a. impaired gas exchange related to cig smokingb. anxiety related to inability to stop smokingc. risk for suffocating related to unfamiliarity with fire prevention guidelinesd. deficient knowledge related to lack of following through of recommendation to stop smoking

c. risk for suffocating related to unfamiliarity with fire prevention guidelines

A nurse working in a pediatricians office receives calls from parents whose children have ingested toxins. What would be the nurses best response?

Call the PCC immediately before attempting any home remedy

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. What information is accurate and should be included in the teaching plan?a. booster seats should be used for children until they are 4'9 and weigh 80-100 poundsb. most US states mandate the use of infant car seats and carriers in a motor vehiclec. infants and toddlers up to 2 years of age should be in a from t facing safety seatd. children older than 6 years may be restrained using a care seat belt in the back seat

a. booster seats should be used for children until they are 4'9 and weigh 80-100 pounds

Based on statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurses priority intervention to prevent trauma when caring for older adults in a nursing home?a. checking to make sure fire alarms are working properlyb. preventing exposure to temperature extremesc. screening for partner or elder abused. making sure patient rooms are decluttered.

d. making sure patient rooms are decluttered

What consideration should the nurse keep in mind regarding the use of side rails for a patient who is confused?a. they prevent confused patients from wanderingb. a history of previous fall from bed with raised side rails is insignificantc. alternative measures are ineffective to prevent wanderingd. a person of small stature is at increased risk for injury from entrapment

d. a person of small stature is at increased risk injury from entrapment

When a fire occurs in a patient's room, what would be the nurse's priority?a. Rescue the patient. b. Extinguish the fire. c. Sound the alarm. d. Run for help.

A. rescue the patient

A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately?a. the nurse includes suggestion son how to prevent the incident from recurringb. the nurse provides minimal info about the incidentc. the nurse discusses the details with the patient before documenting themd. the nurse records the circumstances and effect on the patient in the medical record

d. the nurse records the circumstances and effect on the patient in the medical record

When discussing emergency preparedness with a group of first responders what information would be important to include about preparation for a terrorist attack?a. PTSD can be expected in most survivors of a terrorist attackb. the FDA has collaborated with drug companies to create stockpiles of emergency drugsc. eve small doses of radiation result in bone marrow depression and cancerd. BLI is a serious consequence following detonation of an explosive device

d. BLI is a serious consequence following detonation of an explosive device

An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints?a. Sitting him in a geriatric chair near the nurses' station b. Using the sheets to secure him snugly in his bedc. Keeping the bed in the high positiond. Identifying his door with his picture and a balloon

d. Identifying his door with his picture and a balloon

The joint commission uses guidelines regarding the use of restraints. In which case is a restraint properly used?a. the nurse positions a patient in a supine position prior to applying wrist restraintsb. the nurse ensures that two fingers can be inserted between the restraint and patients anklec. the nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wristd. the nurse ties an elbow restraint to the raised side rail of a patients bed

b. the nurse ensures that two fingers can be inserted between the restraint and patients ankle

A nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine? a. explain how to use the telephoneb. introduce the patient to her roommatec. review the hospital policy visiting hoursd. explain how to operate the call bell

d. explain how to operate the call bell