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A nurse is planning care for a client who has become increasingly anxious and confused. Which of the following actions should the nurse include to avoid the use of physcial restraints? (select all that apply) Elevate all side rails on the bed. Ensure effective pain management. Attend to the client's needs for toileting. Assign the client to a room near the nurses' station. Orient client frequently to the environment.

Ensure effective pain management. Attend to the client's needs for toileting. Assign the client to a room near the nurses' station. Orient client frequently to the environment.

A nurse is planning care for a client who has manifestations of a Clostridium difficile infection. Which of the following actions should the nurse plan to take

Place the client on contact precautions.

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following action should the nurse take?

Secure the restraints using a quick-release tie.

A nurse is discussing the use of mechanical restraints for the newly licensed nurse. Which of the following situation should the nurse include as an indicator for placing a client in mechanical restraints?

Self-destructive behavior despite alternative in interventions

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

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

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take Adjust the water temperature to feel hot. Apply 4 to 5 mL of liquid soap to the hands. Hold the hands higher than the elbows. Rub hands and arms to dry.

Apply 4 to 5 mL of liquid soap to the hands.

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints? The provider must renew a restraint prescription every 8 hr. The client must understand the need for restraints The restraints should promote the client's safety and prevent injuries The nurse has already considered alternatives to restraints

The nurse has already considered alternatives to restraints

A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take?

Wear an N95 respirator mask.

A nurse is having difficulty reading the providers writing one transcribing a prescription for a clients medication. Which of the following actions should the nurse take?

Contact the provider to clarify the prescription.

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

Contact the provider to question the dosage

A nurse is teaching a newly hired group of assistive personnel (AP) about infection control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care?

Performing hand hygiene frequently and consistently

A nurse on a medical-surgical unit is reconciling a new admitted client's medication. The nurse is reveiwing the process of medication reconcilliation with a newly licensed nurse. The nurse should include which of the following information?

The purpose of medication reconciliation is to prevent adverse medication reactions

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and the wheelchair.

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

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

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? Close the fire doors on the unit. Activate the fire alarm. Move any clients in the immediate vicinity. Use a fire extinguisher to put out the fire.

Move any clients in the immediate vicinity.

A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.) - Brace all side rails on the clients bed. - Obtain a prescription to restrain the clients PRN. - Check on the client hourly - Instruct the client in the use of the call light - Apply an ambulation alarm to the clients leg

- Check on the client hourly _ Instruct the client in the use of the call light - Apply an ambulation alarm to the clients leg

A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? (Select all that apply.) - Clients full name - Facility room number - Partners full name - Providers name - Faculty assigned identification number

- Clients full name - Faculty assigned identification number

A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (select all that apply) Document restraint checks and client status every 2 hr. Educate the client's family about restraint use. Obtain the provider's prescription renewal every 72 hr. Implement passive range-of-motion exercises. Release the restraint and reposition the client every 4 hr.

- Document restraint checks and client status every 2 hr. - Educate the client's family about restraint use. - Implement passive range-of-motion exercises.

A nurse is preparing an in-service program about preventing medication errors when transcribing prescription . the nurse is using a dosage example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage .2 mg 0.2 mg 0.20 mg 2.0 mg

0.2 mg

Client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? - Call the clients provider. - Assess the client. - Notify the nurse manager. - Complete an incident report.

Assess the client.

A nurse is preparing to apply wrist restraints to a client to prevent her from pulling out an IV Catheter. WHich of the following actions should the nurse take?

Keep the padded portion of the restraints against the wrists.

A nurse is caring for an older adult 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?

Leave a night light on in the clients room.

A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency. (Move the steps in order)

Rescue Clients Pull Fire Alarm Isolate the Fire Extinguish the Fire


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