Leadership Quiz

A charge nurse is orienting a newly licensed nurse to the facility's policies regarding electronic medical records. Which of the following statements by the newly licensed nurse indicates an understanding of the instructions?

"After I finish with the printout of my assignment, I'll put it in the shredder receptacle."

A nurse on a mental health unit is teaching a newly licensed nurse about client rights. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"Clients on a mental health unit can refuse their medication."

A nurse in a mental health facility is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

"I should request the provider to examine the client within 1 hour of applying mechanical restraints." The provider should evaluate the client within 1 hr of initiation of the mechanical restraint. "I should check the client every 30 minutes while in mechanical restraints."A nurse should constantly observe a client who is in mechanical restraints. "I should use mechanical restraints when a client who is manic starts pacing."A nurse should not restrain a client who is manic and pacing, as this behavior is an expected finding and assists the client in managing excess motor energy. "I should document every hour when a client is in mechanical restraints."A nurse should assess and document every 15 min for range of motion, circulation, and psychological status when a client is in mechanical restraints.

A nurse is teaching an assistive personnel (AP) about caring for a client who has a do-not-resuscitate (DNR) order. Which of the following statements by the AP indicates an understanding of the teaching?

"I will call for the client's nurse to come to the room if I cannot detect the client's pulse."

A nurse manager observes a newly licensed nurse and an assistive personnel (AP) arguing about the failure of the AP to restock unit supplies. The AP leaves the room. Which of the following is an appropriate statement at this time by the nurse manager to the newly licensed nurse?

"I would like for you to approach the AP to resolve the problem."

A charge nurse is discussing issues with a staff nurse. When evaluating statements by the staff nurse, the charge nurse should recognize that which of the following reflects an intrapersonal conflict?

"I'm not sure whether I want to apply for the unit manager's position or start a family this year." The nurse's statement indicates an intrapersonal conflict because the nurse is struggling with competing personal and professional values and desires. "I feel frustrated because I just readmitted a client who refuses to take his insulin."The nurse's statement illustrates an interpersonal conflict with a client. "The unit manager is more concerned with saving money than with clients getting quality care."The nurse's statement illustrates an interpersonal conflict with the nurse manager. "Every time I request an extra day off I'm denied, but other nurses' requests are approved."The nurse's statement illustrates an interpersonal conflict with a nurse manager.

A nurse is caring for a client who has breast cancer and is deciding between two treatment options. Which of the following statements should the nurse make?

"Let's talk about the benefits of each treatment."

A nurse is providing change-of-shift report on four clients. Which of the following statements should the nurse include in the report?

"Miss Graves needs her pain reassessed within the half hour."

A nurse is delegating tasks for a group of clients to an assistive personnel (AP). Which of the following statements by the nurse provides the right direction of communication with the AP?

"Tell me what time the client in room 205 voids for the first time after his catheter is removed."

A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?

"This means I have outlined my wishes for medication treatment." The purpose of advance directives is to outline the client's wishes if he becomes unresponsive. "My partner will need to be present if I become unresponsive."The client's partner does not need to be present if the client comes unresponsive. The nurse should place a copy of the client's advance directives on the medical record so the client's wishes are clear. "My provider will make my health care decisions if I am unable."The client's provider does not make the client's health care decisions if he becomes unable. The provider will follow the client's wishes as outlined in the advance directives. "I cannot make changes to my advance directive once the document is final." The nurse should instruct the client that advance directives can be changed at any time.

A charge nurse is managing conflict with a staff nurse who does not agree with the client care assignment. Which of the following statements is an example of using the conflict resolution strategy known as smoothing?

"You always complete your work on time and do a great job. I believe you can handle the assignment well." The charge nurse is using smoothing as a conflict resolution strategy by complimenting or focusing on shared ideas to reduce the emotional component of the conflict. "Would you accept the assignment if we reassign your client who has total care needs and assign another client who can provide more self-care?"The charge nurse uses compromise by giving up a demand while asking the staff nurse also to give up a demand. "Tell me what changes we need to make so that you'll feel comfortable with the assignment."The charge nurse uses cooperation by giving up her own desires for the desires of the staff nurse. "I didn't mean to make you feel overwhelmed. Why don't you look over the assignments with me and suggest changes?"The charge nurse uses collaboration by putting aside individual desires and focusing on shared decision making.

A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has no orthopedic experience. Which of the following clients should be assigned to the medical nurse?

A client who had a right above-the-knee amputation 24 hr ago

A nurse is receiving report on four clients. Which of the following clients should the nurse plan to assess first?

A client who has a potassium level of 6.5 mEq/L. When using the acute vs chronic approach to client care, the nurse should first assess the client who is at risk for cardiac dysrhythmias; therefore, the nurse should assess the client who has a potassium level of 6.5 mEq/L which indicates hyperkalemia. Cardiac complications of hyperkalemia can include bradycardia, hypotension, complete heart block, and can lead to asystole. A client who had surgery 1 day ago and requests pain medicationA client who is 1 day postoperative and has pain is an expected finding; therefore, there is another client the nurse should assess first. A client who has diabetes mellitus and a fasting blood sugar of 135 mg/dLDiabetes mellitus is a chronic disorder and a fasting blood sugar of 135 mg/dL is an expected finding; therefore, there is another client the nurse should assess first. A client who has COPD and an oxygen saturation of 90% COPD is a chronic disorder and an oxygen saturation of 90% is an expected finding; therefore, there is another client the nurse should assess first.

A nurse in the emergency department is performing triage for a group of clients following a motor vehicle crash. Which of the following clients should the nurse request the provider assess first?

A client who has arm contusions and manifests asymmetrical thoracic movement. A client who has asymmetry of the thorax likely has a tension pneumothorax and requires immediate intervention for survival; therefore, when using the survival approach to client care, the nurse should request the provider to assess this client first. A client who has abrasions to the face and is requesting medication for severe painA client who has abrasions to the face and is requesting medication for severe pain does not have an immediate threat to life and can wait for treatment; therefore, the nurse should not recommend that the provider assess this client first. A client who has a closed leg fracture and reports peripheral paresthesiaA client who has a closed leg fracture does not have an immediate threat to life and can wait for treatment; therefore, the nurse should not recommend that the provider assess this client first. Although the client could have neurological or circulatory complications, another client has a more urgent need. A client who reports a sprained ankle and has a laceration over the medial ankleA client who reports a sprained ankle and has a laceration does not have an immediate threat to life and can wait for treatment; therefore, the nurse should not recommend that the provider assess this client first.

A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

A client who has peripheral vascular disease and has an absent pulse in the right foot

A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse?

A student nurse is photocopying his assigned client's diagnostic test results. Photocopying diagnostic test results is a breach of the client's confidentiality and privacy. An assistive personnel (AP) documents a client's vital signs on the client's paper-based graphic record.Documenting vital signs is within the AP's scope of practice. The unit secretary faxes a client's laboratory results to the provider.Faxing diagnostic test results to the provider is not a breach of confidentiality and privacy if the staff uses security measures, such as verifying the number before sending information, and using a cover sheet. An RN stays with a client who is reading the medical records that he requested.Agency policy might require the nurse to stay with the client who has a legal right to access and read his own medical record.

A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care?

Advise the client to install grab bars in her bathroom at home

A nurse manager is presenting an in-service about preventing readmission of clients due to complications following joint replacement surgery. Which of the following leadership tasks is the nurse performing?

Advocacy The nurse acts as an advocate by promoting and protecting safety for staff and clients by providing information that allows staff to act autonomously. CollaborationCollaboration is a conflict resolution strategy. MediationMediation is a conflict resolution strategy. NegotiationNegotiation is a conflict resolution strategy.

A nurse is caring for four clients. Which of the following assessment findings is the priority?

An adult client who has a femur fracture reports feeling short of breath

A home health nurse is making an initial visit to an older adult client who has COPD and is receiving oxygen. While assessing the home environment for safety, which of the following findings should the nurse recognize as increasing the client's risk for injury? (Select all that apply.)

An office chair with wheels at the client's computer desk is correct. Wheeled chairs create a safety hazard for the client because he may fall while sitting and rising from the chair, especially while managing oxygen equipment. An oxygen tank standing on the floor next to the client's recliner is correct. The client should always keep the oxygen tank in a rack or stand. Otherwise, it is easy to knock it over and risk sudden decompression and uncontrolled movement of the tank, which could cause injury. A raised vinyl seat on the toilet in the client's bathroom is incorrect. A raised toilet seat decreases the client's risk for injury, as it makes it easier to sit and rise without straining joints and risking instability, especially while managing oxygen equipment. A family member smoking on the front porch of the client's home is incorrect. No one should smoke inside the home when oxygen is in use. The safest approach is to ask all smokers to step outside when they smoke. A throw rug over vinyl flooring in the client's bathroom is correct. Covering flooring with a throw rug can increase the client's risk for falls.

A nurse is caring for a client who is scheduled for outpatient surgery. Which of the following actions should the nurse take to verify the client gave informed consent?

Ask the client to explain the procedure that is being performed.

A client on a general surgical unit tells a nurse that staff members are not answering his call light promptly. The client requests to be transferred to another unit. Which of the following actions should the nurse take first?

Ask the client to verbalize his expectations.

A nurse manager is planning daily work and activities for the unit. Which of the following actions is the nurse manager's priority?

Assign client care to staff.

A charge nurse is delegating tasks on a nursing unit that is short staffed. A client has a prescription for a wound irrigation twice a day. Which of the following actions should the charge nurse take?

Assign the procedure to a licensed practical nurse (LPN). This task is within the scope of practice of an LPN. The charge nurse should delegate this task to the LPN. Reschedule the procedure to be performed once daily.It is not within the scope of practice for the RN to change the prescription and this could affect the client's ability to heal. Perform the wound irrigation himself during rounds.This is not an appropriate delegation of tasks. Delegate the procedure to an assistive personnel (AP).It is not within the AP's scope of practice to perform the wound irrigation.

A nurse in a community health clinic is caring for four clients who each have a communicable disease. Which of the following conditions is considered a nationally notifiable infectious disease?

Chlamydia trachomatis

A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure ulcers in a long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan?

Compare data from clients' records regarding skin integrity with established criteria. Chart audits are an efficient and accurate way to measure if a change in a performance improvement indicator has occurred after an intervention is implemented. Measure staff attendance at an educational program on managing pressure ulcers.This is an example of a process audit and does not measure changes in outcomes. Interview clients regarding their satisfaction with their care.While client satisfaction with care is an important indicator, it is not a reliable method for evaluating the effectiveness of the plan. Monitor use of supplies used to prevent pressure ulcers.While this may yield some information about cost, it does not measure the actual outcomes.

An RN is working on the surgical unit when a client who has abdominal pain is admitted. Which of the following activities must be performed by the RN?

Completing the client's initial admission assessment

A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next?

Determine goals and objectives. According to evidence-based practice, the nurse attempting to make a change or revision to a policy should first develop the initial plan and then determine goals and objectives. Objectives define strategies or implementation steps to attain the identified goals. Set target dates for completion.The nurse should set target dates for completion as a later step in the policy revision process; however, evidence-based practice indicates that another action is the priority. Identify areas of support.The nurse should identify areas of support as a later step in the policy revision process; however, evidence-based practice indicates that another action is the priority. The nurse should implement recommended strategies as a later step in the policy revision process; however, evidence-based practice indicates that another action is the priority.

A client is considering having a tubal ligation, and she tells the nurse that she is uncertain if it is the right thing to do. Which of the following is an appropriate response by the nurse?

Discuss the client's feelings about the procedure.

An older adult client is being discharged with a postoperative infection, requiring daily home IV antibiotics through a peripherally inserted central catheter (PICC) line. Which of the following actions should the case manager perform prior to discharge?

Ensure that home infusion therapy has been arranged.

A facility has identified an increase in health care-associated urinary tract infections (UTIs) on the medical-surgical unit. A nurse is participating in a quality improvement process to address this problem. Which of the following should be the first step in the process?

Establish best practice guidelines for reducing the incidence of UTIs. Evidence-based practice indicates the nurse should first establish best practice guidelines for reducing the incidence of UTIs in order to have a standard to measure performance. Determine the effectiveness of planned interventions.The nurse should determine if the planned interventions are effective to determine whether different interventions are needed; however, evidence-based practice indicates that the nurse should take a different action first. Implement strategies to decrease the incidence of UTIs.The nurse should implement strategies to decrease the incidence of UTIs to improve care quality; however, evidence-based practice indicates that the nurse should take a different action first. Develop a plan that outlines the process for data collection.The nurse should develop a plan for data collection to promote consistent data collection and complete results; however, evidence-based practice indicates that the nurse should take a different action first.

A charge nurse recognizes a trend of poor attendance at monthly staff meetings. To address this issue, which of the following actions should the charge nurse take first?

Explore the reasons that staff are not attending the meetings. According to evidence-based practice the nurse should first identify the reasons that staff are not attending the meetings. Change the monthly meetings to quarterly meetings.Changing the monthly meetings to quarterly might improve attendance; however, evidence-based practice indicates that the nurse should take a different action first. Post a memo in the lounge making the monthly meetings mandatory.The nurse should post a memo in the lounge to remind the staff about the meetings; however, evidence-based practice indicates that the nurse should take a different action first. Appoint a task force to promote attendance at the meetings.Appointing a task force to promote attendance at meetings is important to remind the staff about the meetings; however, evidence-based practice indicates that the nurse should take a different action first.

A nurse is caring for a client who requests pain medication. The nurse fulfills a promise to return with the medication within 15 min. The nurse is demonstrating which of the following ethical principles?

Fidelity

A charge nurse is observing a newly licensed nurse's use of time management skills. Which of the following actions by the newly licensed nurse indicates effective use of this skill?

Groups tasks that are in the same location

A facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following is an appropriate action of the charge nurse on the PACU?

Identify stable clients for transfer to a surgical unit.

A nurse on a medical-surgical unit has arrived late to work multiple times over the past several weeks. The nurse manager is planning to use progressive discipline to address this problem. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Issue an informal verbal reprimand. Give the nurse a formal written reprimand. Suspend the nurse without pay. Terminate the nurse's employment.

A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty. Which of the following information can assist the nurse in evaluating the cost effectiveness of the care?

Length of the clients stay.

A nurse in a long-term care facility is transferring a resident to an acute care facility. Which of the following information should the nurse include in the transfer paperwork?

List of current medications

A nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel?

Measuring a client's hourly intake and output. The nurse should delegate measuring intake and output to assistive personnel. The assistive personnel can also document the intake and output in the client's medical record. Applying a nitroglycerin patch for a clientAny type of medication administration, including application of transdermal patches, requires the knowledge and skill of a licensed nurse. Teaching a client how to use crutchesTeaching a client how to use crutches requires the knowledge and skill of a licensed nurse. A registered nurse should provide initial teaching, while a licensed practical nurse can reinforce the teaching as needed. Inserting an NG tube for a clientThis task requires the knowledge and skill of a licensed nurse. Assistive personnel can monitor NG tube intake and output, but cannot insert an NG tube.

A nurse is caring for a client who has a potassium level of 3.2 mEq/L. The nurse has been paging the provider for 1 hr to attempt to report the potassium level. Which of the following interventions should the nurse take next?

Notify the nursing supervisor.

A nurse manager is auditing client charts and identifies an increase in ventilator-associated pneumonia (VAP). Which of the following actions should the nurse manager take?

Notify the quality improvement team.

A nurse is caring for a client who has osteoarthritis and reports difficulty buttoning her clothes. Which of the following referrals should the nurse recommend for the client?

OT The nurse should recommend occupational therapy for a client who has osteoarthritis and reports difficulty with activities of daily living. Occupational therapy can assist the client with exercises to help the client complete these tasks. Respiratory therapyThe client does not exhibit difficulty with her airway, lungs, or breathing; therefore, a referral for respiratory therapy is not needed. Social servicesThe client does not describe problems with financial or domestic issues; therefore, a referral for social services is not needed. Dietary servicesThe client does not report problems with her diet; therefore, a referral for dietary services is not needed.

A nurse assumes care of a client following change-of-shift report and notes that the client's morning laboratory results have not been received. Which of the following actions should the nurse take?

Obtain a capillary blood glucose reading.

A nurse manager is planning an in-service for a group of nurses about caring for clients following stem cell transplants. Which of the following instructions should the nurse manager include in the teaching?

Place clients in positive-pressure airflow rooms. The nurse should place a client who requires protective environment precautions following a stem cell transplant in a private, positive-pressure airflow room. The room air is filtered through a HEPA filter and the airflow rate is set at more than 12 air exchanges each hour. Assign two clients who have had a stem cell transplant to the same room.The nurse should only cohort two clients in a semi-private room if they are infected with the same pathogen. The nurse should assign clients who have had a stem cell transplant in private rooms to reduce the risk of infection. Obtain a rectal temperature on clients every 4 hr.The nurse should choose another route for measuring temperature to avoid introducing microorganisms that can cause an infection. Wear an N95 respirator mask while caring for these clients.Health care personnel should wear an N95 respirator mask while caring for clients who require airborne precautions. These masks protect the nurse from inhaling contaminated droplet nuclei.

A charge nurse on a medical-surgical unit is planning care for a client who has dementia and is being admitted for surgery. Which of the following would promote safety when caring for this client?

Placing the client in a room near the nurses' station. The nurse should place the client in a room near the nurses' station and observe the client frequently to reduce the risk of injury. Requesting the client be transferred to another unitRequesting that the client be transferred to another unit does not ensure the safety of the client. Requiring that a family member stay with the client during waking hoursIt is inappropriate for the nurse to require a family member to stay with the client. Care of the client and ensuring client safety is the responsibility of the nurse. Clients who have dementia are at greater risk for wandering at nighttime. Maintaining four side rails in the up position on the client's bedMaintaining four side rails in the up position is considered a restraint, and a provider's prescription is required for restraint. This action increases the client's risk for injury.

A nurse is reviewing safe use of a wheelchair with a group of assistive personnel. Which of the following should the nurse include?

Raise the footplates of the wheelchair before transferring the client.

A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

Receiving moderate sedation

An RN delegates the task of obtaining the blood pressure of a client who is 2 hr postoperative following a cholecystectomy to a licensed practical nurse (LPN). The LPN reports a blood pressure that is significantly higher than the client's previous reading. Which of the following actions should the RN take first?

Recheck the client's blood pressure. The first action the nurse should take using the nursing process is to assess the client; therefore, the nurse should recheck the client's blood pressure after 1 to 2 min to confirm the reading. Treat the client's blood pressure with a prescribed antihypertensive.The nurse may need to administer a prescribed antihypertensive to treat the client's blood pressure; however, there is another action the nurse should take first. Ask the LPN to review the technique for obtaining blood pressure.The nurse might need to ask the LPN to review the technique for obtaining blood pressure to ensure he knows how to do the procedure; however, there is another action the nurse should take first. Review the client's medical record for other episodes of elevated blood pressure.The nurse should review the client's medical record for other episodes of elevated blood pressure to identify a trend; however, there is another action the nurse should take first.

A nurse walks into the nurses' station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the nurse take first?

Remind the staff members that this is a breach of confidentiality. When using the urgent vs nonurgent approach to client care, the nurse determines that the first action is to intervene immediately to prevent any further breach in confidentiality. Discuss the issue with the nurse manager.Discussing the issue with the nurse manager is nonurgent because this action does not stop the occurring breach of confidentiality; therefore, there is another action that is the nurse's priority. Request that an administrative restriction be placed on the client's record access.Requesting that an administrative restriction be placed on the client's record access is nonurgent because this action does not stop the occurring breach of confidentiality; therefore, there is another action that is the nurse's priority. Prepare a memo for the facility ethics committee.Preparing a memo for the facility ethics committee is nonurgent because this action does not stop the occurring breach of confidentiality; therefore, there is another action that is the nurse's priority.

A nurse notices a frayed cord attached to an infusion pump in a client's room. Which of the following actions should the nurse take?

Report the pump with the frayed cord to the maintenance department.

A nurse at an urgent care clinic notices that a pain assessment is not being performed for all clients as required by policy. Which of the following actions should the nurse take?

Report this issue to the nurse manager.

A nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task?

Review the AP's skill competency checklist.

A nurse is caring for a client who is experiencing adverse effects after receiving a new medication. Which of the following communication tools should the nurse use for management of this complication?

SBAR framework

A nurse manager confronts a nurse who has the smell of alcohol on her breath. After the nurse is sent home, which of the following actions should the nurse manager take?

Set up a formal meeting with the nurse within 24 hr. Once the nurse manager has removed the nurse from the work environment and arranged for safe transportation home, the nurse manager should arrange to meet with the nurse within the next 24 hours. The nurse manager is to confront the nurse who was chemically impaired and clearly identify the facility's expectations. Report the nurse's chemical impairment to the risk manager.Impaired employees are not reported to risk management. The nurse manager should outline the rehabilitation measures for the nurse who is chemically impaired. Provide a series of counseling sessions with the nurse.The nurse manager is not responsible for taking on the role of counselor or treatment provider for an impaired nurse. Talk with the nurse's coworkers to determine a potential cause for the impairment. The nurse manager should not discuss the nurse's situation with coworkers nor diagnose a cause for the impairment. The nurse manager should handle the incident in a confidential manner.

A nurse is preparing assignments for the upcoming shift. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Suction a client's chronic tracheostomy.

A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as appropriate sterile technique?

The nurse places the sterile package with the top flap opening away from her. The nurse should place the sterile package on a flat surface so that the top flap opens away from her. This prevents the contents of the sterile package from becoming contaminated. The nurse pinches the flap on the inside of the package first to open it.The nurse should pinch the flap on the outside of the package first to open it. The nurse reaches over the package to open the left flap.The nurse should open the left flap of the package with her left hand. This prevents the nurse from reaching over the package and contaminating the contents of the package. The nurse pulls the last flap of the package away from her body.The nurse should pull the last flap of the package toward her body by pulling the corner down. This prevents the contents of the package from becoming contaminated.

An 18-year-old client in remission with rhabdomyosarcoma has just been diagnosed with metastasis to the bone. The client says that he does not want to have chemotherapy again. Which of the following statements is consistent with the client's rights?

The nurse states, "I can gather information about palliative care for you." The nurse is acknowledging the client's right to refuse treatment and is demonstrating support by offering to discuss end-of-life care options. The case manager states, "I will page the chaplain to discuss this decision with you."The case manager is making an assumption about the client's religious beliefs and spiritual needs. The parent states, "I want to become my son's durable power of attorney."An 18-year-old client is legally able to make decisions about his own care. The client has the right to refuse treatment without parental involvement. The provider states, "I need to discuss treatment options with your parents." An 18-year-old client is legally able to make decisions about his own care. The client has the right to refuse treatment.

A nurse manager is reviewing the actions a staff nurse took when she observed smoke coming from a wastebasket in a client's room. The nurse manager should verify that the nurse acted appropriately when she performed which of the following actions first?

Transported the client to the hallway. The greatest risk to this client is injury from a fire; therefore, the first action the nurse should take using the RACE protocol is to remove the client from the area of danger. Closed the door to the client's roomThe nurse should close the door to the client's room to confine the fire; however, according to the RACE protocol, this is not the first action the nurse should take. Initiated the fire alarm systemThe nurse should activate the fire alarm system to acquire additional help; however, according to the RACE protocol, this is not the first action the nurse should take. The nurse should attempt to extinguish the fire using a fire extinguisher appropriate to the type of fire; however, according to the RACE protocol, this is not the first action the nurse should take.

A nurse is applying restraints to a client who is combative. Which of the following actions should the nurse take?

Use a quick-release tie to secure the restraint. Remove the restraint every 4 hr to assess the client's condition.The nurse should remove the restraint at least every 2 hr to assess the client's condition. Use a quick-release tie to secure the restraint.MY ANSWERThe nurse should secure the restraint with a quick-release tie. The nurse should not secure the restraint with a knot in case the restraint needs to be removed quickly in an emergency. Secure the restraint to the side rails of the client's bed.The nurse should secure the restraint to a portion of the bed frame that moves when raising or lowering the bed. Securing the restraint to the bed rail can lead to injury if the rail is lowered. Apply a belt restraint under the client's hospital gown.The nurse should apply a belt restraint over a client's hospital gown or clothing to reduce the risk for injury. The nurse should ensure the clothing under the restraint is wrinkle-free.

A nurse is caring for a client who has cancer and vomits blood on the bed linens and the floor. Which of the following actions should the nurse take to safely clean the environment?

mop floors and clean with bleach