2024\2025 A+ Grade
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.
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.
- correct answer 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 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?
Notify the nursing supervisor
Tear up and discard the incident report
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
- correct answer Tell the primary health care provider that the error warrants the completion of an
incident report
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?
To transfer the client to a semiprivate 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 wear a gown when caring for the client and remove the gown immediately after leaving the client's
room
- correct answer To wear gloves and a gown when changing the client's bed linen.
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?
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 on the primary health care provider's answering service about the incident
- correct answer Call a poison control center
,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?
Activate the agency disaster plan
Supply the triage rooms with additional equipment
Increase the number of nursing staff for the day on which the hurricane is expected
Call the hospital maintenance department to secure the building against the storm
- correct answer Activate the agency disaster plan
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
understands the directions? Select all that apply.
"I need to follow the oxygen prescription exactly."
"I can use my electric razor while I'm using oxygen."
"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."
"I have to tell everyone that they can't smoke or have an open flame within 10 feet (3 meters) of the
oxygen concentrator."
- correct answer "I need to follow the oxygen prescription exactly."
"I have to keep the oxygen concentrator out of direct sunlight."
"I have to tell everyone that they can't smoke or have an open flame within 10 feet (3 meters) of the
oxygen concentrator."
, 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 2 hours
Every 3 hours
Every 4 hours
Every 30 minutes
- correct answer q2hrs
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
Planning a focused child safety program
Performing an analysis of health problems related to child safety
Determining the appropriateness of the planned health activity
- correct answer Determining the appropriateness of the planned health activity
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?
An incident report was completed and filed.