FONP Module 4

A nurse is preparing to administer oral medications to a client. Which of the following should a nurse recognize as an acceptable client identifier? (Select all that apply) A. Client's full name B. Facility room number C. Partner's full name D. Provider's name E. Facility-assigned identification number

A. Client's full name E. Facility-assigned identification number

A nurse is caring for a group of client's on a medical-surgical unit. Which of the following situations requires that the nurse wears gloves? (Select all that apply) A. Emptying urine from an indwelling urine collection bag B. Providing oral care C. Changing an ostomy pouch D. Delivering a food tray to a client who has AIDS E. Placing oral medication tablets into a client's hand

A. Emptying urine from an indwelling urine collection bag B. Providing oral care C. Changing an ostomy pouch

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? A. Secure the restraints using a quick-release tie. B. Ensure four fingers fit under the restraints to prevent constriction. C. Secure the restraints to the lowest bar of the side rail. D. Anticipate removing the restraints every 4 hr.

A. Secure the restraints using a quick-release tie.

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include? A. "If you wear gloves, you do not have to wash your hands." B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." C. "Use an alcohol rub when your hands are visibly soiled." D. "If you don't have an infection, your hands won't infect others."

B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."

A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include? A. "The client attempted to climb over the side rails and fell." B. "The client was lying on the floor next to his bed." C. "The client was restless and trying to get out of bed all evening." D. "The presence of a bed alarm could have prevented the client from falling."

B. "The client was lying on the floor next to his bed."

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? A. Place the wheelchair at a 90° angle to the bed. B. Lock the wheels of the bed and the wheelchair. C. Acquire the help of several people to lift the client. D. Elevate the bed to a position of comfort for the nurse.

B. Lock the wheels of the bed and the wheelchair.

A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take? A. Make a copy of the incident report for the provider. B. Submit the incident report to the risk manager. C. Place the incident report in the client's chart. D. Document in the chart that an incidence report has been filed.

B. Submit the incident report to the risk manager.

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply) A. Keep the client's room dark at night. B. Teach the client to use the call light. C. Keep the client's bed in the lowest position. D. Place a fall-risk identification band on the client's wrist. E. Assess the client every 4 hr.

B. Teach the client to use the call light. C. Keep the client's bed in the lowest position. D. Place a fall-risk identification band on the client's wrist.

A nurse accidentally sticks her hand with a syringe after administering an IM injection to a client. Which of the following actions should the nurse take first? A. Report the incident to the charge nurse. B. Wash the area of the puncture thoroughly with soap and water. C. Complete an incident report. D. Go to employee health services.

B. Wash the area of the puncture thoroughly with soap and water.

A nurse is caring for several client's. For which of the following situations should the nurse complete an incident report? A. The nurse identifies a broken piece of equipment. B. A staff member does not show up to work her assigned shift. C. A client discovers that his dentures are missing. D. The nurse has a disagreement with the nursing supervisor about inadequate staffing.

C. A client discovers that his dentures are missing.

A nurse is caring for an older client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? A. Limit the client's fluid intake in the evening. B. Obtain a bedside commode for the client's use. C. Leave a nightlight on in the client's room. D. Put the side rails up and tell the client to call the nurse before voiding.

C. Leave a nightlight on in the client's room.

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? A. Close the fire doors on the unit. B. Activate the fire alarm. C. Move any clients in the immediate vicinity. D. Use a fire extinguisher to put out the fire.

C. Move any clients in the immediate vicinity.

A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first? A. Apply a vest restraint on the client. B. Place the client in bed with the two side rails raised. C. Place a seat alarm in the client's chair. D. Administer lorazepam the client.

C. Place a seat alarm in the client's chair.

A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety? A. The client pushes downward on the hand grips. B. The client stands in a tripod position prior to walking. C. The client places partial weight on the affected leg. D. The client keeps the elbows in a flexed position.

C. The client places partial weight on the affected leg.

A nurse is orienting a new assistive personnel (AP) to the unit. Which of the following actions should the nurse intervene? A. Wears a gown when entering the room of a client who requires contact precautions B. Dons gloves to empty a urinary drainage device C. Washes and rinses her hands for 10 seconds D. Wears a respirator mask when entering the room of a client who requires airborne precautions

C. Washes and rinses her hands for 10 seconds

A nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statements indicates an understanding of the teaching? A. "I will apply elastic bandages to cuts." B. "I will use dishwashing gloves when cleaning the dishes." C. "I will buy balloons for my son's birthday." D. "I will use ink pens for writing."

D. "I will use ink pens for writing."

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? A. "There were no injuries sustained." B. "An incident report was completed." C. "An incident report was forwarded to the risk manager." D. "The provider was notified."

D. "The provider was notified."

A client is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include? A. Relax her abdominal muscles while lifting objects. B. Twist at the waist when she moves an object to one side. C. Hold an object away from her body while she lifts it. D. Bend at the knees when picking up an object.

D. Bend at the knees when picking up an object.

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control? A. Shakes the soiled linen to remove any toilet paper remnants. B. Places the soiled linen on the floor before bagging it. C. Holds the soiled linen against her body while carrying it to the linen bag. D. Places clean linen that touched the floor in the soiled linen bag.

D. Places clean linen that touched the floor in the soiled linen bag

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply) A. Bathtub with rails B. Electric cords behind the furniture C. Raised toilet seats D. Water heater temperature 54.4°C (130° F) E. Throw rugs

D. Water heater temperature 54.4°C (130° F) E. Throw rugs