Kilgore College NURSING 1429041 Module 6 EXAM QUESTIONS AND ANSWERS

Questions 1. Which event would require a nurse to complete and file an incident report? o A client has a seizure. o The nurse determines that a client would benefit from the use of a walker to ambulate. o The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. o 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. 2. A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol (Tenormin) 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 physician to report the error. The physician 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? o Notifying the nursing supervisor o Tearing up and discarding the incident report o Telling the physician that the error warrants the completion of an incident report o Telling the nursing supervisor that the physician did not want an incident report completed and filed 3. Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant: o To transfer the client to a semiprivate room o That gloves only are needed to care for the client o To wear gloves and a gown when changing the client's bed linen. o To wear a gown when caring for the client and remove the gown immediately after leaving the client’s room 4. A nurse hears someone calling, “Help! My bed is on fire!” On entering the room, the nurse finds a client trying to beat out the flames with a pillow. Place in order of priority the actions that the nurse should take: o 2 Pulling the nearest fire alarm o 3 Closing the door to the room o 4 Running to get the nearest fire extinguisher o 1 Removing the client from the room 5. 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. The nurse should instruct the mother to immediately: o Call a poison control center o Administer an excessive amount of fluids to induce vomiting o Call an ambulance to bring the child to the emergency department o Leave a message at the physician answering service about the incident 6. 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? o Activating the agency disaster plan o Supplying the triage rooms with additional equipment o Increasing the number of nursing staff for the day on which the hurricane is expected o Calling the hospital maintenance department to secure the building against the storm 7. A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client has understood the directions? Select all that apply. o “I need to follow the oxygen prescription exactly.” o “I can use my electric razor while I’m using oxygen.” o “I have to keep the oxygen concentrator out of direct sunlight.” o “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” o “I have to tell everyone that they can’t smoke or have an open flame within 10 feet (3 meters) of the oxygen concentrator.” 8. A nurse is providing instructions to a nursing assistant who will be caring for a client in hand restraints. The nurse instructs the nursing assistant to release the restraints to permit muscle exercise: o Every 2 hours o Every 3 hours o Every 4 hours o Every 30 minutes 9. A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. In this situation, the most appropriate initial action is: o Implementing a child safety program o Planning a focused child safety program o Performing an analysis of health problems related to child safety o Determining the appropriateness of the planned health activity 10. The nurse administers a dose of ramipril (Altace) 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 physician and nursing supervisor of the error. What statement does the nurse add to the client’s record? o An incident report was completed and filed. o Ramipril (Altace) 2.5 mg was administered at 9 am. o Twice the amount of the prescribed ramipril was administered at 9 am. o Client’s blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril. 11. 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? o The client’s bed is in a low position. o The client is oriented to person, place, and time. o The caregiver uses the overbed table for feedings. o The caregiver leaves both siderails down while the client is in bed. 12. A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. o Skin o Lungs o Immune o Urinary o Lymphatic o Gastrointestinal 13. 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? o Wearing gloves and a mask o Wearing gloves and a gown o Wearing gloves, a mask, and eye protection o Wearing gloves, a mask, and a head covering