Module 6 - HESI Safety & Infection Control || Elite-Level
Questions with Correct Solutions.
Which event would require a nurse to complete and file an incident report?
The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion
pump is not working.
A client has a seizure.
When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure
and takes the visitor to the emergency department for treatment.
The nurse determines that a client would benefit from the use of a walker to ambulate. correct
answers When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood
pressure and takes the visitor to the emergency department for treatment.
Rationale: An incident is any event that is not consistent with the routine operation of a
healthcare unit or routine care of a client. Examples of incidents include client falls, needlestick
injuries, a visitor having signs/symptoms of illness, medication administration errors, accidental
omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An
incident report does not need to be filed if a client has a seizure unless the client sustains injury
as a result of the seizure. If the nurse determines that a client would benefit from the use of a
walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes
that the battery of an intravenous infusion pump is not working, he/she should obtain a
functioning pump and send the nonfunctioning pump to the appropriate department for repair.
A nurse, charting the administration of medications to an assigned client at 9 pm, notes that
atenolol was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client's
vital signs, completes an incident report, and calls the primary health care provider to report the
error. The primary health care provider tells the nurse that an incident report is not needed but
instructs her to monitor the client during the night for hypotension. What action should the nurse
take?
Tell the primary health care provider that the error warrants the completion of an incident report
Tell the nursing supervisor that the primary health care provider did not want an incident report
completed and filed
Tear up and discard the incident report
Notify the nursing supervisor correct answers Tell the primary health care provider that the error
warrants the completion of an incident report
Rationale: Incident reports are an important part of a healthcare agency's quality improvement
program. An incident is any event that is not consistent with the routine operation of a healthcare
unit or routine care of a client. An example of an incident is administering a medication at a time
at which it is not prescribed to be given. Whenever an incident occurs, an incident report is
completed and filed in accordance with agency guidelines. The nursing supervisor would be
notified of the incident; however, on the basis of the data in the question, the nurse should tell the
,primary health care provider that the error warrants completion and follow-through with an
incident report. Therefore, the other options are incorrect.
Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus
(MRSA) infection. What does the nurse, providing instructions to a nursing assistant about
caring for the client, tell the assistant?
That gloves only are needed to care for the client
To wear gloves and a gown when changing the client's bed linen.
To wear a gown when caring for the client and remove the gown immediately after leaving the
client's room
To transfer the client to a semiprivate room correct answers To wear gloves and a gown when
changing the client's bed linen.
Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client
contact is anticipated. Goggles are worn to protect the mucous membranes of the eye during
interventions that may produce splashes of blood or body fluids, secretions, or excretions. The
client should be placed in a private room or, if a private room is not available, in a semiprivate
room with another client who has active infection with the same microorganism but no other
infection. The nursing assistant would remove the protective gear before leaving the client's
room.
The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank
some window cleaner that had been stored in a cabinet. What should the nurse instruct the
mother to do immediately?
Administer an excessive amount of fluids to induce vomiting
Call a poison control center
Leave a message on the primary health care provider's answering service about the incident
Call an ambulance to bring the child to the emergency department correct answers Call a poison
control center
Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting
should not be induced if the victim is unconscious or if the substance ingested was a strong
corrosive or petroleum product. Also, vomiting should not be induced unless a primary
healthcare provider has given specific instructions to induce vomiting. Neither calling an
ambulance nor calling the primary health care provider's answering service is the immediate
action because either would delay treatment. Additionally, the primary health care provider
would immediately make a referral to the poison control center. The poison control center may
advise the mother to bring the child to the emergency department; if this is the case, the mother
should then call an ambulance.
A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department
of an area hospital is advised to prepare for causalities. Which action should the nurse manager
who receives the telephone call regarding this warning take first?
,Increase the number of nursing staff for the day on which the hurricane is expected
Supply the triage rooms with additional equipment
Activate the agency disaster plan
Call the hospital maintenance department to secure the building against the storm correct
answers Activate the agency disaster plan
Rationale: In an external disaster, many people may be brought to the emergency department for
treatment. Although increasing the nursing staff and supplying the triage rooms with additional
equipment may be steps in preparing for casualties, the initial action by the nurse manager must
be activation of the disaster plan. Calling the hospital maintenance department to secure the
building from the storm is not a responsibility that falls within the scope of nursing management.
A nurse is providing instructions to a nursing assistant who will be caring for a client in hand
restraints. How often does the nurse instruct the nursing assistant to release the restraints to
permit muscle exercises?
Every 30 minutes
Every 3 hours
Every 4 hours
Every 2 hours correct answers Every 2 hours
Rationale: The nurse should instruct the nursing assistant to assess the restraints and the client's
circulatory status and skin integrity every 30 minutes. Restraints must be released at least every 2
hours to permit muscle exercise and promote circulation. Agency guidelines regarding the use of
restraints should always be followed.
A community health nurse working in a school setting is concerned because parents are not
participating in health activities designed to promote child safety. What is the most appropriate
initial action for the nurse to take?
Implementing a child safety program
Determining the appropriateness of the planned health activity
Performing an analysis of health problems related to child safety
Planning a focused child safety program correct answers Determining the appropriateness of the
planned health activity
Rationale: In this situation, the most appropriate initial action would be to determine the
appropriateness of the planned health activities. This would be followed by analysis, planning,
and implementation.
The nurse administers a dose of ramipril 2.5 mg to a client at 9 am. While documenting
administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the
prescribed dose. The nurse assesses the client, completes an incident report, and notifies the
primary health care provider and nursing supervisor of the error. What statement does the nurse
add to the client's record?
, Client's blood pressure was 128/82 mm Hg after the administration of the incorrect dose of
ramipril.
An incident report was completed and filed.
Twice the amount of the prescribed ramipril was administered at 9 am.
Ramipril 2.5 mg was administered at 9 am. correct answers Ramipril 2.5 mg was administered at
9 am.
Rationale: After an incident, the nurse would document a concise and objective description of
what occurred and any follow-up actions taken in the client's record. The nurse would not
document in the client's record that an incident report was completed. Nor would the nurse
document that twice the prescribed dose was given or that an incorrect dose was given.
A home health nurse has been called to the home of an older postoperative cardiovascular client
by the client's son. The son tells the nurse, "We're using a hospital bed here at home, but my
mother has fallen out of bed three times." Which observation by the nurse reflects an increased
risk of this client's falling out of bed?
The caregiver leaves both side rails down while the client is in bed.
The client is oriented to person, place, and time.
The client's bed is in a low position.
The caregiver uses the overbed table for feedings. correct answers The caregiver leaves both side
rails down while the client is in bed.
Rationale: Leaving the side rails of older client's bed down may increase the client's risk of
falling. The aging process also increases this client's potential for falls; therefore, evaluating the
safety of the environment is a necessity. Keeping the client's bed in a low position, orientating
the client to the environment, and using the overbed table for feedings are all ways to help ensure
the client's safety.
A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of
Hodgkin's disease. Which precaution should the nurse take while working with this intravenous
(IV) infusion?
Wearing gloves and a mask
Wearing gloves and a gown
Wearing gloves, a mask, and a head covering
Wearing gloves, a mask, and eye protection correct answers Wearing gloves, a mask, and eye
protection
Rationale: When handling chemotherapeutic agents, the nurse should wear disposable latex
gloves, a mask that covers the nose and mouth, and eye protection, especially if a biological
hood is not available. Wearing gloves and a mask or gloves and a gown will not provide
adequate protection. A head covering is not necessary.
Questions with Correct Solutions.
Which event would require a nurse to complete and file an incident report?
The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion
pump is not working.
A client has a seizure.
When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure
and takes the visitor to the emergency department for treatment.
The nurse determines that a client would benefit from the use of a walker to ambulate. correct
answers When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood
pressure and takes the visitor to the emergency department for treatment.
Rationale: An incident is any event that is not consistent with the routine operation of a
healthcare unit or routine care of a client. Examples of incidents include client falls, needlestick
injuries, a visitor having signs/symptoms of illness, medication administration errors, accidental
omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An
incident report does not need to be filed if a client has a seizure unless the client sustains injury
as a result of the seizure. If the nurse determines that a client would benefit from the use of a
walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes
that the battery of an intravenous infusion pump is not working, he/she should obtain a
functioning pump and send the nonfunctioning pump to the appropriate department for repair.
A nurse, charting the administration of medications to an assigned client at 9 pm, notes that
atenolol was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client's
vital signs, completes an incident report, and calls the primary health care provider to report the
error. The primary health care provider tells the nurse that an incident report is not needed but
instructs her to monitor the client during the night for hypotension. What action should the nurse
take?
Tell the primary health care provider that the error warrants the completion of an incident report
Tell the nursing supervisor that the primary health care provider did not want an incident report
completed and filed
Tear up and discard the incident report
Notify the nursing supervisor correct answers Tell the primary health care provider that the error
warrants the completion of an incident report
Rationale: Incident reports are an important part of a healthcare agency's quality improvement
program. An incident is any event that is not consistent with the routine operation of a healthcare
unit or routine care of a client. An example of an incident is administering a medication at a time
at which it is not prescribed to be given. Whenever an incident occurs, an incident report is
completed and filed in accordance with agency guidelines. The nursing supervisor would be
notified of the incident; however, on the basis of the data in the question, the nurse should tell the
,primary health care provider that the error warrants completion and follow-through with an
incident report. Therefore, the other options are incorrect.
Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus
(MRSA) infection. What does the nurse, providing instructions to a nursing assistant about
caring for the client, tell the assistant?
That gloves only are needed to care for the client
To wear gloves and a gown when changing the client's bed linen.
To wear a gown when caring for the client and remove the gown immediately after leaving the
client's room
To transfer the client to a semiprivate room correct answers To wear gloves and a gown when
changing the client's bed linen.
Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client
contact is anticipated. Goggles are worn to protect the mucous membranes of the eye during
interventions that may produce splashes of blood or body fluids, secretions, or excretions. The
client should be placed in a private room or, if a private room is not available, in a semiprivate
room with another client who has active infection with the same microorganism but no other
infection. The nursing assistant would remove the protective gear before leaving the client's
room.
The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank
some window cleaner that had been stored in a cabinet. What should the nurse instruct the
mother to do immediately?
Administer an excessive amount of fluids to induce vomiting
Call a poison control center
Leave a message on the primary health care provider's answering service about the incident
Call an ambulance to bring the child to the emergency department correct answers Call a poison
control center
Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting
should not be induced if the victim is unconscious or if the substance ingested was a strong
corrosive or petroleum product. Also, vomiting should not be induced unless a primary
healthcare provider has given specific instructions to induce vomiting. Neither calling an
ambulance nor calling the primary health care provider's answering service is the immediate
action because either would delay treatment. Additionally, the primary health care provider
would immediately make a referral to the poison control center. The poison control center may
advise the mother to bring the child to the emergency department; if this is the case, the mother
should then call an ambulance.
A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department
of an area hospital is advised to prepare for causalities. Which action should the nurse manager
who receives the telephone call regarding this warning take first?
,Increase the number of nursing staff for the day on which the hurricane is expected
Supply the triage rooms with additional equipment
Activate the agency disaster plan
Call the hospital maintenance department to secure the building against the storm correct
answers Activate the agency disaster plan
Rationale: In an external disaster, many people may be brought to the emergency department for
treatment. Although increasing the nursing staff and supplying the triage rooms with additional
equipment may be steps in preparing for casualties, the initial action by the nurse manager must
be activation of the disaster plan. Calling the hospital maintenance department to secure the
building from the storm is not a responsibility that falls within the scope of nursing management.
A nurse is providing instructions to a nursing assistant who will be caring for a client in hand
restraints. How often does the nurse instruct the nursing assistant to release the restraints to
permit muscle exercises?
Every 30 minutes
Every 3 hours
Every 4 hours
Every 2 hours correct answers Every 2 hours
Rationale: The nurse should instruct the nursing assistant to assess the restraints and the client's
circulatory status and skin integrity every 30 minutes. Restraints must be released at least every 2
hours to permit muscle exercise and promote circulation. Agency guidelines regarding the use of
restraints should always be followed.
A community health nurse working in a school setting is concerned because parents are not
participating in health activities designed to promote child safety. What is the most appropriate
initial action for the nurse to take?
Implementing a child safety program
Determining the appropriateness of the planned health activity
Performing an analysis of health problems related to child safety
Planning a focused child safety program correct answers Determining the appropriateness of the
planned health activity
Rationale: In this situation, the most appropriate initial action would be to determine the
appropriateness of the planned health activities. This would be followed by analysis, planning,
and implementation.
The nurse administers a dose of ramipril 2.5 mg to a client at 9 am. While documenting
administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the
prescribed dose. The nurse assesses the client, completes an incident report, and notifies the
primary health care provider and nursing supervisor of the error. What statement does the nurse
add to the client's record?
, Client's blood pressure was 128/82 mm Hg after the administration of the incorrect dose of
ramipril.
An incident report was completed and filed.
Twice the amount of the prescribed ramipril was administered at 9 am.
Ramipril 2.5 mg was administered at 9 am. correct answers Ramipril 2.5 mg was administered at
9 am.
Rationale: After an incident, the nurse would document a concise and objective description of
what occurred and any follow-up actions taken in the client's record. The nurse would not
document in the client's record that an incident report was completed. Nor would the nurse
document that twice the prescribed dose was given or that an incorrect dose was given.
A home health nurse has been called to the home of an older postoperative cardiovascular client
by the client's son. The son tells the nurse, "We're using a hospital bed here at home, but my
mother has fallen out of bed three times." Which observation by the nurse reflects an increased
risk of this client's falling out of bed?
The caregiver leaves both side rails down while the client is in bed.
The client is oriented to person, place, and time.
The client's bed is in a low position.
The caregiver uses the overbed table for feedings. correct answers The caregiver leaves both side
rails down while the client is in bed.
Rationale: Leaving the side rails of older client's bed down may increase the client's risk of
falling. The aging process also increases this client's potential for falls; therefore, evaluating the
safety of the environment is a necessity. Keeping the client's bed in a low position, orientating
the client to the environment, and using the overbed table for feedings are all ways to help ensure
the client's safety.
A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of
Hodgkin's disease. Which precaution should the nurse take while working with this intravenous
(IV) infusion?
Wearing gloves and a mask
Wearing gloves and a gown
Wearing gloves, a mask, and a head covering
Wearing gloves, a mask, and eye protection correct answers Wearing gloves, a mask, and eye
protection
Rationale: When handling chemotherapeutic agents, the nurse should wear disposable latex
gloves, a mask that covers the nose and mouth, and eye protection, especially if a biological
hood is not available. Wearing gloves and a mask or gloves and a gown will not provide
adequate protection. A head covering is not necessary.
