Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39)

Question 1 1 / 1 pts Which event would require a nurse to complete and file an incident report? A client has a seizure. The nurse determines that a client would benefit from the use of a walker to ambulate. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. Correct! 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 health care 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. Test-Taking Strategy: Use knowledge of the subject, reasons for filing an incident report, to assist you with the process of elimination. Read each option carefully. Recalling that an incident is any event that is not consistent with the routine operation of a health care 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. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Notifying the nursing supervisor Tearing up and discarding the incident report Correct! Telling the health care provider that the error warrants the completion of an incident report Telling the nursing supervisor that the health care provider did not want an incident report completed and filed Rationale: Incident reports are an important part of a health care agency’s quality improvement program. An incident is any event that is not consistent with the routine operation of a health care 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 health care provider that the error warrants completion and follow-through with an incident report. Therefore, the other options are incorrect. Test-Taking Strategy: Focus on the subject of the question, the health care provider’s telling the nurse that an incident report is not needed. Eliminate the comparable or alike options that 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. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal 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 to take which action? To transfer the client to a semiprivate room That gloves only are needed to care for the client Correct! 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 Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client contact is anticipated. 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. Test-Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed-ended 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. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management 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 take which action? Correct! Call a poison control center. Administer an excessive amount of fluids to induce vomiting. Call an ambulance to bring the child to the emergency department. Leave a message at the health care provider answering service about the incident. 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 health care provider has given specific instructions to induce vomiting. Neither calling an ambulance nor calling the health care provider’s answering service is the immediate action, because either would delay treatment. Additionally, the 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. Test-Taking 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 comparable or alike 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. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Increasing the number of nursing staff for the day on which the hurricane is expected Calling the hospital maintenance department to secure the building against the storm 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. Test-Taking 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. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters “I can use my electric razor while I’m using oxygen.” Correct! “I have to keep the oxygen concentrator out of direct sunlight.” “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” Correct! “I have to tell everyone that they can’t smoke or have an open flame within 10 feet of the oxygen concentrator.” Rationale: The client should follow the oxygen prescription exactly. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use, because fire and injury to the client could result. The oxygen concentrator is kept out of direct sunlight and slightly away from walls and corners to permit adequate air flow. The client should not allow smoking or any type of flame within 10 feet of the oxygen source. Other measures include having telephone numbers for the health care provider, nurse, and oxygen vendor available and teaching the client signs and symptoms requiring emergency care. Test-Taking Strategy: Recall knowledge of the subject, oxygen safety measures, to assist you with eliminating options. Recall that one hazard associated with oxygen is ignition, which could result from heat in the form of flames or sparks. Evaluating the question from this perspective, eliminate the options that are unsafe. Review oxygen safety measures if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Safety A nurse is providing instructions to a nursing student who will be caring for a client in hand restraints. The nurse instructs the nursing student to release the restraints to permit muscle exercise how frequently? Correct! Every 2 hours Every 3 hours Every 4 hours Every 30 minutes Rationale: The nurse should 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. Test-Taking Strategy: Knowledge regarding the subject, the use of restraints, is necessary to answer this question. Noting the strategic words “release the restraints” will help direct you to the correct option. Review nursing responsibilities regarding the use of restraints if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Implementing a child safety program Planning a focused child safety program Performing an analysis of health problems related to child safety Correct! Determining the appropriateness of the planned health activity Rationale: In this situation, the best initial action would be to determine the appropriateness of the planned health activities. This would be followed by analysis, planning, and implementation. Test-Taking Strategy: Use the steps of the nursing process to answer the question. Note that the correct option involves the process of data collection, the first step of the nursing process. Review the procedure for planning health activities to provide safety if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Correct! Ramipril (Altace) 2.5 mg was administered at 9 a.m. Twice the amount of the prescribed ramipril was administered at 9 a.m. Client’s blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril. 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. Test-Taking Strategy: Focus on the data in the question. Recall that notes made in a client’s record must be objective. Eliminate the comparable or alike options that indicate that an incorrect dose of medication was administered. Next note that the correct option clearly and accurately describes the incident in an objective manner. Review documentation of a medication error or other incident if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal The client’s bed is in a low position. The client is oriented to person, place, and time. The caregiver uses the overbed table for feedings. Correct! The caregiver leaves both siderails down while the client is in bed. Rationale: Leaving the siderails 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. Test-Taking Strategy: Use the process of elimination, focusing on the subject, an observation of an unsafe practice. Noting that the question indicates that the bed is in the low position and that the client is oriented will assist you in eliminating these options. To select from the remaining options, choose the one that identifies an unsafe practice. Review the causes of falls in an older client if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Safety Correct! Skin Correct! Lungs Immune Urinary Lymphatic Correct! Gastrointestinal Rationale: Anthrax, caused by Bacillus anthracis, can be contracted through the gastrointestinal system, abrasions in the skin, or inhalation. It is not contracted through the immune system, urinary tract, or lymphatic system. Test-Taking Strategy: Specific knowledge of the subject, the routes of infection with B. anthracis, is needed to answer this question. Remember that anthrax can be contracted through the gastrointestinal system, skin, or lungs. Review content on anthrax and its modes of transmission if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Biological/chemical warfare Wearing gloves and a gown Correct! Wearing gloves, a mask, and eye protection Wearing gloves, a mask, and a head covering 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. Test-Taking Strategy: Knowledge regarding the subject, precautions for handling chemotherapeutic agents, is necessary to answer this question. Think about the effects and cytotoxic nature of chemotherapy to answer the question. Select the option that will provide the greatest degree of protection to the nurse handling chemotherapeutic agents. If you had difficulty with this question, review the precautions for handling a chemotherapy infusion. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety