While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device.
Which of the following actions should the nurse take first?
Report the defect to the equipment maintenance staff.
Remove the device from the room.
Initiate a requisition for a replacement CPM device.
Ensure the device inspection sticker is current.
The Correct Answer is B
The correct answer is b. Remove the device from the room.
Choice A rationale:
- Reporting the defect to the equipment maintenance staff is essential, but it's not the immediate priority. The primary concern is to eliminate the safety hazard posed by the frayed cord to prevent potential harm to the client and others.
- Delaying the removal of the device could lead to electrical shock, fire, or other serious consequences.
- Therefore, removing the device from the room takes precedence over reporting the defect.
Choice B rationale:
- Removing the device from the room is the most appropriate first action because it:
- Eliminates the immediate safety hazard.
- Prevents potential harm to the client and others.
- Protects the device from further damage.
- Ensures the safety of the environment.
- Demonstrates the nurse's prioritization of patient safety.
Choice C rationale:
- Initiating a requisition for a replacement CPM device is necessary to ensure the client's continued treatment.
- However, it's not the first action because it doesn't address the immediate safety concern.
- The nurse should first remove the faulty device and then initiate the process for obtaining a replacement.
Choice D rationale:
- Ensuring the device inspection sticker is current is a vital part of equipment maintenance.
- However, it's not relevant to the immediate safety issue of the frayed cord.
- The presence of a current inspection sticker doesn't guarantee the device's safety or functionality at that moment.
- The nurse must prioritize removing the hazard and then follow up with appropriate documentation and reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Testing skin turgor on the abdomen is common in infants and young children, but in older adults, abdominal skin often loses elasticity due to aging, making it an unreliable site for assessment.
Choice B rationale: The skin over the sternum or the subclavicular area (shoulder/chest) is the most reliable site for older adults. These areas typically maintain more elastic tissue, providing a more accurate reflection of hydration.
Choice C rationale: Assessing the stomach is essentially the same as the abdomen. This site is prone to skin sagging and loss of subcutaneous fat in elderly patients, which can lead to false-positive signs of dehydration.
Choice D rationale: The skin on the neck is thin and highly susceptible to wrinkles and sun damage. Lifting the skin here in an older adult will often show "tenting" even if the patient is well-hydrated.
Correct Answer is B
Explanation
The correct answer is B.
Previous violent behavior. According to the web search results, this is the best predictor of future violence among the given risk factors.
Other risk factors include past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders).
Choice A is wrong because a history of being in prison is not a direct cause of violence, but rather a possible consequence of it.
Choice C is wrong because male gender is not a sufficient factor to predict violence, as there are many other variables involved. Choice D is wrong because experiencing delusions is not necessarily associated with violence, unless they are of a paranoid or persecutory nature.
Normal ranges for violence risk assessment are not standardized, but some tools that can be used include the Historical Clinical Risk Management-20 (HCR-20), the Violence Risk Appraisal Guide (VRAG), and the Psychopathy Checklist-Revised (PCL-R). These tools use different scales and criteria to evaluate the likelihood of violent behavior in individuals.
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