Foundations and Adult Health Nursing - Chapter 10 (NCLEX)

An adult patient is brought to the emergency department for treatment of an unintentional poisoning. What is the nurse's first action in caring for this patient? 1. Induce vomiting. 2. Assess the patient. 3. Place the patient in an upright position. 4. Notify the poison control center.

2. Assess the patient.

The nurse is documenting on a patient with an SRD. What information must the nurse include in this documentation? 1. The nurse's feelings about having used the SRD. 2. The specific type of SRD used and assessment of the patient. 3. Confirmation of a prn order for use of the SRD. 4. Evidence that the patient was assessed every 8 hours.

2. The specific type of SRD used and assessment of the patient.

When the staff's knowledge of the fire safety precautions is assessed, which action indicates the need for further fire safety instruction? (Select all that apply.) 1. Fire exits and corridors are kept clear. 2. A No Smoking sign is posted when oxygen is in use. 3. A heating pad cord is taped when a frayed area is noted. 4. Facility smoking policies are a part of the admission procedure for patients. 5. An UAP evacuated critically ill patients on the elevator during a fire drill.

3. A heating pad cord is taped when a frayed area is noted. 5. An UAP evacuated critically ill patients on the elevator during a fire drill.

The nurse is caring for a patient on a ventilator and reads the order "restrain prn." The nurse considers which factor when caring for this patient? (Select all that apply.) 1. SRDs often decrease anxiety because the patient feels safer. 2. All older adult patients need some type of SRD at night. 3. Allow as much freedom of movement as possible when applying SRDs. 4. When using soft SRDs to prevent pulling of the ventilator tubing, tie them to the side rail. 5. Ensure that the nurse's two fingers can be inserted between the SRD and the patient's skin.

3. Allow as much freedom of movement as possible when applying SRDs. 5. Ensure that the nurse's two fingers can be inserted between the SRD and the patient's skin.

The nurse is providing home poison control instruction to the parent of a 2-year-old boy. Which statement by the parent indicates the need for further teaching? 1. "I will call the national poison control center if my child ingests a poisonous substance." 2. "I will call 911 immediately if my child ingests medication that is not intended for him." 3. "Child safety caps on household cleaner can still be opened by some children." 4. "I will give my child syrup of ipecac if he ingests a poisonous substance that is not caustic."

4. "I will give my child syrup of ipecac if he ingests a poisonous substance that is not caustic."

The home health nurse is assessing a child for the risk of injury. Which factor places a child at greatest risk for specific types of injuries? 1. Gender of the child 2. Overall health 3. Educational level 4. Developmental level

4. Developmental level

A type C fire extinguisher is required for which type of fire? 1. Paper 2. Cloth 3. Grease 4. Electrical

4. Electrical

The occupational health nurse learns of a mercury spill that occurred in the factory in which she is employed. Which action by the nurse is correct? 1. The nurse cleans the mercury spill with alcohol and ordinary cleaning cloths. 2. The nurse closes all windows and doors to prevent the mercury spill from spreading out of the area. 3. The nurse instructs the housekeeping staff to vacuum up the spill. 4. The nurse evacuates the area and contacts trained personnel to clean up the spill.

4. The nurse evacuates the area and contacts trained personnel to clean up the spill.

The LPN/LVN is reviewing the admission information of a patient. Which information is of most concern to the nurse that this patient is at high risk for falling? 1. The patient has diabetes. 2. The patient had a stroke 3 years ago with no complications. 3. The patient becomes disoriented in the evening hours. 4. The patient wears eyeglasses and a hearing aid.

4. The patient wears eyeglasses and a hearing aid.

The LPN/LVN is reviewing the care plan of the patient who has an SRD applied for personal safety. Which is the highest priority goal for this patient? 1. Patient will remain free of injury. 2. Patient will allow SRDs to be used. 3. Nurse will check SRD every 30 minutes. 4. Use least restrictive form of SRD possible.

1. Patient will remain free of injury.

During the 7 a.m. to 3 p.m. shift on the adult surgical unit, the code is announced for an external disaster emergency. Which event best represents this type of situation? 1. A school bus accident 2. A bomb threat in the mail room 3. A hostage-taking event in the emergency department 4. An electrical fire in the maintenance department

1. A school bus accident

The home health nurse is visiting an older adult patient and her husband. What safety concern is of the highest priority when the nurse is assessing this patient's home environment? 1. Accidental poisoning 2. Electrical shock 3. Accidental falls 4. Thermal burns

1. Accidental poisoning

When caring for the patient who requires the use of an SRD, what should be included in the patient's plan of care? (Select all that apply.) 1. Monitor the skin for signs of impairment. 2. Remove the SRD once every 2 hours. 3. Secure the ends of the ties to the side rails. 4. Ensure that the SRD is in place at all times. 5. Reevaluate the need for the SRD frequently.

1. Monitor the skin for signs of impairment. 2. Remove the SRD once every 2 hours. 5. Reevaluate the need for the SRD frequently.

The nurse discovers smoke in a soiled utility room across the hall from a patient's room. What should the nurse's initial action be? 1. Sound the fire alarm. 2. Disconnect the oxygen supply. 3. Use any extinguisher on the fire. 4. Remove the patient from the area.

1. Sound the fire alarm.

The nurse is observing the UAP who is assisting a resident in a long-term care facility ambulate with a gait belt. Which action by the UAP indicates to the nurse that further instruction is necessary? (Select all that apply.) 1. The UAP loosely fastens the gait belt around the patient's waist. 2. The UAP places the gait belt on the resident before assisting the resident to a standing position. 3. The UAP grasps the gait belt while assisting the resident out of bed. 4. The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair. 5. The UAP explains to the resident that the gait belt is used to prevent injury to the resident and the UAP when assisting with ambulation.

1. The UAP loosely fastens the gait belt around the patient's waist. 4. The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair.