Exam (elaborations) Safety and infection control

Question 1 1 / 1 pts Which of the following events would require a nurse to complete and file an incident report? 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. A client has a seizure. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. The nurse determines that a client would benefit from the use of a walker to ambulate. 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 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 or she should obtain a functioning pump and send the nonfunctioning pump to the appropriate department for repair. Test­Taking Strategy: Use the process of elimination and read each option carefully. Recalling that an incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client will direct you to the correct option. Review the reasons for filing an incident report if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 336, 337, 403). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 2 1 / 1 pts 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? Tearing up and discarding the incident report Telling the physician that the error warrants the completion of an incident report Telling the nursing supervisor that the physician did not want an incident report completed and filed Notifying the nursing supervisor 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 physician that the error warrants completion and follow­through with an incident report. Therefore, the other options are incorrect. Test­Taking Strategy: Focus on the subject of the question, the physician’s telling the nurse that an incident report is not needed. Eliminate the options that are comparable or alike in that they involve notifying the nursing supervisor. To select from the remaining options, recall the purpose of an incident report to select the correct option. Review the procedures involved in completing and filing incident reports if you had difficulty with this question. Reference: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 557, 558). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 3 1 / 1 pts Contact precautions are initiated for a client with methicillin­resistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant: To wear a gown when caring for the client and remove the gown immediately after leaving the client s room That gloves only are needed to care for the client To wear gloves and a gown when changing the client's bed linen. To transfer the client to a semiprivate room 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. Test­Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed­ended word only. Next eliminate the option that involves removal of the gown after leaving the client s room. To select from the remaining options, read each carefully and visualize the procedure instituted for contact precautions, which will direct you to the correct option. If you had difficulty with this question, review contact precautions. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 655, 663). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Question 4 1 / 1 pts The mother of a 3­year­old 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: Call a poison control center Leave a message at the physician answering service about the incident Administer an excessive amount of fluids to induce vomiting Call an ambulance to bring the child to the emergency department 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 healthcare provider has given specific instructions to induce vomiting. Neither calling an ambulance nor calling the physician s answering service is the immediate action, because either would delay treatment. Additionally, the physician 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. Test­Taking Strategy: Note the strategic word immediately in the query of the question. First, recalling that vomiting should not be induced without appropriate advice to do so will help you eliminate the option that involves inducing vomiting. Next eliminate the options that will delay treatment (i.e., calling an ambulance and leaving a message with the answering service). Review immediate poison control measures if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal­child nursing (3rd ed., pp. 120, 121). St. Louis: Elsevier. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 5 1 / 1 pts 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? Activating the agency disaster plan Calling the hospital maintenance department to secure the building against the storm Supplying the triage rooms with additional equipment Increasing the number of nursing staff for the day on which the hurricane is expected 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. Test­Taking Strategy: Note the strategic word “first” in the query of the question. Use the process of elimination in determining the priority action. Note that the correct option is the umbrella option. Also remember that other necessary activities will be initiated once the agency disaster plan has been activated. Review procedures related to management in times of disaster if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2009). Medical­surgical nursing: Clinical management for positive outcomes (8th ed., pp. 76, 2213, 2214). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disaster