leadership exam 3 study guide

a nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. the client has manifestations of which of the following conditions? allergic rxn ringworm systemic lupus erythematosus TB

TB

A nurse manager is providing information about the audit process to members of the nursing team. Which of the following information should the nurse manager include? (select all that apply) a. a structure audit evaluates the setting and resources available to provide care b. an outcome audit evaluates the results of the nursing care provided c. a root cause analysis is indicated when a sentinel event occurs d. retrospective audits are conducted while the client is receiving care e. after data collection is completed, it is compared to a benchmark

a. a structure audit evaluates the setting and resources available to provide care b. an outcome audit evaluates the results of the nursing care provided c. a root cause analysis is indicated when a sentinel event occurs e. after data collection is completed, it is compared to a benchmark

A nurse manager is developing an orientation plan for newly licensed nurses. Which of the following information should the manager include in the plan? a. skill proficiency b. assignment to a preceptor c. budgetary principles d. computerized charting e. socialization into unit culture f. facility policies and procedures

a. skill proficiency b. assignment to a preceptor d. computerized charting e. socialization into unit culture f. facility policies and procedures

With the rise in workplace violence in the emergency department, the nurse manager decides that she should work with the risk manager in violence prevention. The nurse manager should: a.Request all staff to accept new risk management practices. b.Hold staff accountable for safe practices. c.Document inappropriate behavior. d.Hire more police security.

b.Hold staff accountable for safe practices.

A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following information will provide data regarding the efficacy of the procedure? a. frequency with which procedure is performed b. client satisfaction with performance of procedure c. incidence of complications related to procedure d. accurate documentation of how procedure was performed

c. incidence of complications related to procedure

The nurse manager is concerned about the negative ratings her unit has received on patient satisfaction surveys. The first step in addressing this issue from the point of view of quality improvement is to: a.Assemble a team. b.Establish a benchmark. c.Identify a clinical activity for review. d.Establish outcomes.

c.Identify a clinical activity for review.

A new graduate is asked to serve on the hospital's quality improvement (QI) committee. The nurse understands that the first step in quality improvement is to: a.Collect data to determine whether standards are being met. b.Implement a plan to correct the problem. c.Identify the standard d.Determine whether the findings warrant correction.

c.Identify the standard

A nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent healthcare-associated infections (HAIs). Which of the following infections should the nurse include? (Select all that apply)

catheter-associated urinary tract infection central line associated bloodstream infection sx site infection

a nurse is caring for a client who has a hx of falls. which of the following actions is the nurse's priority? complete a fall-risk assessment educate the client and family about fall risks eliminate safety hazards from the client's environment make sure the client uses assistive aids in their posession

complete a fall-risk assessment

A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains the needed element for fire to occur? (Select all that apply)

cooking oil oxygen heat.

A method commonly used in Quality Assurance to monitor adherence to established standards is: a.A Pareto chart. b.Brainstorming .c.Patient interviews. d.Chart audit.

d.Chart audit.

The nurse gives an inaccurate dose of medication to a patient. After assessment of the patient, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication understands that: a.The error will result in suspension. b.An incident report is optional for an event that does not result in injury. c.The error will be documented in her personnel file. d.Risk management programs are not designed to assign blame.

d.Risk management programs are not designed to assign blame.

4 measures to prevent electrical shock

disconnect all equipment prior to cleaning ensure that outlet covers are used in areas ensure that outlets are not overcrowded use extension cords only when absolute necessary

A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (Select all that apply)

fall hix medical dx assistive devices mental status

a charge nurse is reviewing with a newly hired nurse the difference in manifestion of a localized vs. a systemic infection. which of the following are manifestations of a systemic infection? SATA fever malaise edema pain or tenderness increase in pulse and RR

fever malaise increase in pulse and RR

A hospital in an urban setting is located on two rivers which are spanned by several bridges. Resources arrive to this community via commercial trains or airplanes. Which credible threats should this hospital prepare for when constructing the emergency preparedness plan? Select all that apply.

floods bridge collapses boating accidents train derailments

a nurse is planning safety interventions at a new clinic. which of the following interventions should the nurse include? have staff who will be performing x-rays wear dosimeters provide both latex and non-latex gloves for employees place sharps containers outside clients rooms provide electrical tape for staff to repair frayed cords

have staff who will be performing x-rays wear dosimeters

a home health nurse is assessing the safety of a client's home. the nurse should identify which of the following factors as increasing the client's risk for falls? SATA history of a previous fall reduced vision impaired memory takes rosuvastatin uses a night light kyphosis

history of a previous fall reduced vision impaired memory kyphosis

a nurse educator is presenting a module on basic first aid for newly licensed home health nurses. the client who has a heat stroke will have which of the following? hypotension bradycardia clammy skin bradypnea

hypotension

a nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. which of the following statements by a nurse requires further instruction? i will place the client on their side i will go to the nurse's station for assistance i will note the time that the seizure begins i will prepare to insert an airway

i will go to the nurse's station for assistance

a nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. the client is experiencing which of the following stages of infection? prodromal incubation convalescence illness

illness

a home health nurse is discussing the dangers of food poisoning with a client. which of the following information should the nurse include? SATA most food poisoning is caused by a virus immunocompromised individuals are at increased risk for complications from food poisoning clients who are at high risk should eat or drink only pasteurized dairy products healthy individuals usually recover from the illness in a few weeks handling raw and fresh food separately can prevent food poisoning

immunocompromised individuals are at increased risk for complications from food poisoning clients who are at high risk should eat or drink only pasteurized dairy products handling raw and fresh food separately can prevent food poisoning

A nurse enters the room of a client who is on contact precautions and finds the client lying on the floor. Which of the following actions should the nurse take first?

inspect the client for injuries

a nurse is reviewing the hospital's fire safety policies and procedures with a newly hired AP. the nurse is describing what to do when there is a fire in the client's trash can. which of the following information should the nurse include? SATA the first step is to pull the alarm use a class C fire extinguisher to put out the fire instruct ambulatory client to evacuate to a safe place pull the pin on the fire extinguisher prior to use close all doors

instruct ambulatory client to evacuate to a safe place pull the pin on the fire extinguisher prior to use close all doors

a nurse is caring for a client who fell at a nursing home. the client is oriented to person, place, and time and can follow directions. which of the following actions should the nurse take to decrease the risk of another fall? SATA place a belt restraint on the client when they are sitting on the bedside commode keep the bed in its lowest position with all side rails up make sure that the client's call light is within reach provide the client with nonskid footwear complete a fall-risk assessment

make sure that the client's call light is within reach provide the client with nonskid footwear complete a fall-risk assessment

a nurse is caring for a client who had a stroke and is at risk of falling. which of the following actions should the nurse take? assign the client to a private room keep 4 side rails up while the client is in bed monitor the client at least once q 1 hour request a PRN rx for restraints

monitor the client at least once q 1 hour

a nurse observes smoking coming from under the door of the staff's lounge. which of the following actions is the nurse's priority? extinguish the fire activate the fire alarm move clients who are nearby close all open doors on the unit

move clients who are nearby

a nurse is providing discharge instructions to a client who has a rx for O2 use at home. which of the following information should the nurse include? SATA family members who smoke must be at least 10 ft from the client when oxygen is in use nail polish should not be used near a client who is receiving oxygen a "no smoking" sign should be placed on the front door cotton bedding and clothing should be replaced with items made from wool a fire extinguisher should be readily avail. in the home

nail polish should not be used near a client who is receiving oxygen a "no smoking" sign should be placed on the front door a fire extinguisher should be readily avail. in the home

a nurse educator is conducting a parenting class for new guardians of infants. which of the following statements made by a participants indicates understanding? i will set my water heater at 130 once my baby can sit up, they should be safe in the bath tub i will place my baby on their stomach to sleep once my infant starts to push up, i will remove the mobile from over the crib

once my infant starts to push up, i will remove the mobile from over the crib

a nurse is a member of a quality improvement committee seeking to reduce the risk of adverse events in a health care facility. when reviewing submitted incident reports, which of the following incidents should the nurse identify as a sentinel event? paralysis of a client's lower extremities occurred following epidural anesthesia a client falling during ambulation did not result in a client injury a client's family member complained that a nurse was culturally insensitive surgery to the wrong site was stopped prior to a procedure

paralysis of a client's lower extremities occurred following epidural anesthesia

A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a healthcare-associated infection?

perform hand hygiene

a nurse discovers a small paper fire in a trash can in a client's bathroom. the client has been taken to safety and the alarm has been activated. which of the following actions should the nurse take? open the windows in the clients room to allow smoke to escape obtain a class c fire extinguisher to extinguish the fire remove all electrical equipment from the client's room place wet towels along the base of the door to the client's room

place wet towels along the base of the door to the client's room

a nurse is caring for a client who has SARS. the nurse knows that health care professioanls are required to report communicable and infectious diseases. which of the following illustrate the rationale for reporting? SATA planning and evaluating control and prevention strategies determining public health priorities ensuring proper medical tx identify endemic disease monitoring for common-source outbreaks

planning and evaluating control and prevention strategies determining public health priorities ensuring proper medical tx monitoring for common-source outbreaks

A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take?

remove the restraints with each vital sign check

A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin. Which of the following actions should the nurse take?

rinse the client's skin with water

a nurse on a acute care unit is caring for a client following a total hip arthroplasty. the client is confused, moving the affected leg into positions that could dislocate the new hip joint, and repeatedly attempting to get out of bed. after determining that restraint application is indicated, which of the following actions should the nurse take? SATA secure the restraint to the frame of the bed get a rx for restraints from the provider have a family member sign the consent for restraints tie the restraint to the side rail using a double knot ensure that only one finger can be inserted between the restraint and the client

secure the restraint to the frame of the bed get a rx for restraints from the provider have a family member sign the consent for restraints

identify the frequency in which the nurse should check equipment

the nurse should check all equipment at the beginning and end of each shift

a nurse is observing a newly licensed nurse and an AP pull a client up in a bed using a drawsheet. which of the following actions by the newly licensed nurse indicates an understanding of this technique? the nurse stands with both feet together the nurse uses their body weight to counter the client's weight the nurse's feet are facing inward, toward the center of the bed the nurse rotates the waist while pulling the client upward

the nurse uses their body weight to counter the client's weight

What is the oldest model of nursing? A. Modular nursing B. Total patient care C. Primary care D. Case management

total patient care

a nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected dx of pertussis. which of the following interventions should the nurse include? SATA place the client in a room that has a negative air pressure of at least 6 exchanges per hour wear a mask when providing care within 3 ft of the client place a surgical mask on the client if transportation to another department is unavoidable use sterile gloves when handling soiled linens wear a gown when performing care that might result in contamination from secretions

wear a mask when providing care within 3 ft of the client place a surgical mask on the client if transportation to another department is unavoidable wear a gown when performing care that might result in contamination from secretions

A staff nurse at the nurse's station answers the phone and is told there is a bomb in a client's room. What action should the nurse take? 1. put call on hold and obtain charge nurse 2. transfer call to security 3. ask caller for details about the bomb placement 4. signal to staff to close the clients door

3. ask caller for details about the bomb placement

The nurse is working in a long-term care facility and is observing a new unlicensed assistive personnel (UAP) caring for a client who requires wrist restraints. The nurse determines that the unlicensed assistive personnel (UAP) is providing safe care if the nurse observed the UAP assessing skin integrity by completely removing the client's wrist restraints using which time frame? A. Every 2 hours B. Every 3 hours C. Every 4 hours D. Every 6 hours

A. Every 2 hours

When responding to the call bell, the nurse finds the client lying on the floor. After a thorough assessment and appropriate care, the nurse completes an incident report. What information should be included? A. The client fell out of bed. B. The client climbed over the side rails. C. The client was found lying on the floor. D. The client was restless and got out of bed.

C. The client was found lying on the floor.

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 home health nurse is discussing the dangers of carbon monoxide poisoning with a client. which of the following information should the nurse include? Co2 has a distinct odor water heaters should be inspected every 5 years the lungs are damaged from Co2 inhalation Co2 binds with hemoglobin in the body

Co2 binds with hemoglobin in the body

The nurse must place a wrist restraint on a client. The client tells the nurse that he does not want to wear the restraint. Which is the best nursing action to implement at this time? A. Sedate the client first B. Apply the wrist restraint. C. Contact the client's family. D. Reconsider alternative measures.

D. Reconsider alternative measures.

5. The nurse is caring for a patient with a urinary catheter. After the nurse empties the collectionbag and disposes of the urine, the next step is to A. Use alcohol-based gel on hands. B. Wash hands with soap and water. C. Remove eye protection and dispose of in garbage. D. Remove gloves and dispose of in garbage.

D. Remove gloves and dispose of in garbage.

A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?

Review the events leading up to each medication administration error.

stages of infection

incubation prodromal acute infection convalescence

The nurse manager is designated as a unit Chief during the formulation of a Hospital Incident Command System (HICS) for disaster preparedness. Which responsibility does the nurse manager assume in this role?

logistics and operation

A nurse witnesses another nurse providing care without proper hand hygiene and reports this to the charge nurse. The charge nurse is friends with the other nurse and refuses to take action. This is an examples of:

moral distress

A nurse is checking a client's allergy bracelet before administering a medication and finds the client allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events?

near miss event

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?1. I should request the provider to examine the client within 1 hour of applying mechanical restraints.2. I should check the client every 30 minutes

"I should request the provider to examine the client within 1 hour of applying mechanical restraints."

How does the nurse support a culture of safety? (Select all that apply.) 1 Completing incident reports when appropriate 2 Completing incident reports for a near miss 3 Communicating product concerns to an immediate supervisor 4 Identifying the person responsible for an incident

1 Completing incident reports when appropriate 2 Completing incident reports for a near miss 3 Communicating product concerns to an immediate supervisor

To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply.) 1 Smoking is prohibited around oxygen. 2 Demonstrate how to adjust the oxygen flow rate based on patient symptoms. 3 Do not use electrical equipment around oxygen. 4 Special precautions may be required when traveling with oxygen

1 Smoking is prohibited around oxygen. 3 Do not use electrical equipment around oxygen. 4 Special precautions may be required when traveling with oxygen

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) 1 Contact the nursing supervisor. 2 Restrict the family's visiting privileges. 3 Ask the family to stay with the patient if possible. 4 Inform the family of the risks associated with side-rail use. 5 Thank the family for being conscientious and put the four rails up. 6 Discuss alternatives with the family that are appropriate for this patient.

3 Ask the family to stay with the patient if possible. 4 Inform the family of the risks associated with side-rail use. 6 Discuss alternatives with the family that are appropriate for this patient.

The nurse-manager notes an unacceptable rate of falls on the unit. Hourly rounds by nursing staff are initiated. What is the best method to determine that the change has made a difference? 1. Scores on client satisfaction surveys 2. surveys on staff's perception of the effectiveness 3. comparing fall rates after the rounds are initiated 4. documentation that the rounds are completed as scheduled

3. comparing fall rates after the rounds are initiated

The patient has been diagnosed with a respiratory illness and complains of shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. What is the usual comfort range for most patients? A. 65° F to 75° F B. 60° F to 75° F C. 15° C to 17° C D. 25° C to 28° C

A. 65° F to 75° F

Which patient has the highest risk of falling? A. A 75-year old female with episodes of syncope. B. A 36-year old female with a fractured tibia. C. A 22-year old male with 3 fractured ribs and right arm in a cast. D. A 63-year old male with angina pectoris.

A. A 75-year old female with episodes of syncope.

A nurse manager is explaining the use of incident reports to a group of nurses in an orientation program. Which of the following information should the nurse manager include? (Select all that apply) A. A description of the incident should be documented in the clients healthcare record. B. The client should sign as a witness on the incident report. C. Incident reports include a description of the incident and actions taken. D. A copy of the incident report should be placed in the clients healthcare record. E. The risk management department

A. A description of the incident should be documented in the clients healthcare record. C. Incident reports include a description of the incident and actions taken. E. The risk management department

The nurse manager is providing an educational session to the nursing staff in a skilled nursing facility on the guidelines for the safe use of physical restraints. Which are safe guidelines? Select all that apply. A. A health care provider's prescription is required. B. Restraints should be secured with a quick-release tie. C. Restraints are secured to side rails so that they can be easily removed as necessary. D. Restraints are used when other measures have failed to prevent self-injury or injury to others. E. Restraints can be used as a usual part of treatment plans, as indicated by the client's condition or symptoms. F. The use of restraints can be prescribed PRN (as needed) as long as the nurse performs a thorough assessment before applying them.

A. A health care provider's prescription is required. B. Restraints should be secured with a quick-release tie. D. Restraints are used when other measures have failed to prevent self-injury or injury to others.

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: A. A safe environment promotes patient activity. B. Assessment focuses on environmental factors only. C. Teaching home safety is difficult to do in the hospital setting. D. Most accidents in the older adult are caused by lifestyle factors.

A. A safe environment promotes patient activity.

The home health nurse is caring for a patient in the home who is using an electrical infusion device. While visiting the patient, the nurse smells smoke and notices an electrical fire started by this device. The nurse uses the fire extinguisher and fights the fire when (Select all that apply.) A. All occupants have left the home. B. Fire department has been called. C. Fire is confined to one room. D. An exit route is available. E. The correct extinguisher is available. F. The nurse thinks she can use the fire extinguisher.

A. All occupants have left the home. B. Fire department has been called. D. An exit route is available. E. The correct extinguisher is available.

The nurse is caring for a group of medical-surgical patients. The unit has been notified of afire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which of the following should the nurse implement? (Select all that apply.) A. Close all doors. B. Note evacuation routes. C. Note oxygen shut-offs. D. Await direction from the fire department. E. Evacuate everyone from the building. F. Review "Stop, drop, and roll" with the nursing staff

A. Close all doors. B. Note evacuation routes. C. Note oxygen shut-offs. D. Await direction from the fire department.

The nurse manager is creating a plan of action for the emergency department in the event of an internal fire. What should the nurse include in the plan? Select all that apply. A. Direct ambulating clients to walk to a safe location. B. Continue oxygen for all clients to reduce damage to lung tissue. C. Remove all clients from danger before attempting to extinguish the fire. D. Wait for the fire department to arrive before initiating the plan of action. E. Move bedridden clients away from the fire area by use of beds or stretchers.

A. Direct ambulating clients to walk to a safe location. C. Remove all clients from danger before attempting to extinguish the fire. E. Move bedridden clients away from the fire area by use of beds or stretchers.

The Quality Improvement Team is considering an initiative to prevent falls. Which action will be most successful? A. Frequent rounds of patient rooms. B. Placing all beds in the low position. C. Using color-coded wristbands. D. Putting a "Fall Risk" sign on patient doors

A. Frequent rounds of patient rooms.

The nursing assistant is caring for a client who had a hip pinned after being fractured. The registered nurse intervenes and determines the nursing assistant needs further teaching if the nurse observes the nursing assistant taking which action? A. Leaving both side rails down on the bed B. Answering the client's call bell promptly C. Keeping the call bell within the client's reach D. Placing the client's personal articles and telephone within reach

A. Leaving both side rails down on the bed

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: A. Place a bed alarm device on the bed. B. Place the patient in a belt restraint. C. Provide one-on-one observation of the patient. D. Apply wrist restraints.

A. Place a bed alarm device on the bed.

The nurse manager is updating the trauma center's policies regarding internal disasters, such as a fire. Which action by the nurse meets the outcome of maintaining client, staff, and visitor safety? Select all that apply. A. Removing clients from harm's way B. Evacuating visitors away from a fire C. Avoiding risk while putting out a fire D. Leaving the facility immediately and going directly home E. Discontinuing oxygen on clients who can breathe without it

A. Removing clients from harm's way B. Evacuating visitors away from a fire C. Avoiding risk while putting out a fire E. Discontinuing oxygen on clients who can breathe without it

Equipment-related accidents are risks in the health care agency. The nurse assesses for this risk when using A. Sequential compression devices. B. A measuring device that measures urine. C. Computer-based documentation. D. A manual medication-dispensing device

A. Sequential compression devices.

The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which of the following should the patient avoid? (Select all thatapply.) A. Watering outdoor plants with a nozzle and hose B. Purchasing light bulbs with strength greater than 60 watts C. Missing yearly eye examinations D. Using bathtubs without safety strips E. Unsecured rugs throughout the home F. Walking to the mailbox in the summer

A. Watering outdoor plants with a nozzle and hose B. Purchasing light bulbs with strength greater than 60 watts C. Missing yearly eye examinations D. Using bathtubs without safety strips E. Unsecured rugs throughout the home

The nurse administers digoxin (Lanoxin) 0.25 mg by mouth rather than the prescribed dose of 0.125 mg to the client. Which should the nurse implement first? A. Write an incident report. B. Tell the client about the medication error. C. Administer digoxin immune Fab (Digibind). D. Tell the client about the adverse effects of digoxin.

A. Write an incident report.

A nurse is teaching a community group of school-aged parents about safety. The most important item to prioritize and explain is how to check the proper fit of A. a bicycle helmet. B. swimming goggles. C. soccer shin guards. D. baseball sliding shorts.

A. a bicycle helmet.

A diabetic client survives a fire. The client has a head injury, tachycardia, and pale and ashen-colored skin. Which primary interventions should the nurse perform? Select all that apply.

Administering cool intravenous fluids Placing the client in a cool environment Managing and maintaining airway, breathing, and circulation`

The nurse administers furosemide (Lasix) 80 mg by mouth, but the prescription is written for furosemide 40 mg by mouth. Which should the nurse document on an incident report? A. "I gave the wrong dose of the medication." B. "Furosemide (Lasix) 80 mg by mouth administered." C. "A double dose of furosemide was given to the client." D. "Furosemide 80 mg given to the client instead of 40 mg."

B. "Furosemide (Lasix) 80 mg by mouth administered."

The registered nurse (RN) is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply. A. "An event is termed a mass casualty when it overwhelms local medical capabilities." B. "Mass casualty events do not require an increase in the number of staff needed." C. "A mass casualty event occurs only within the heath care facility and could endanger staff." D. "Mass casualty events may require the collaboration of many local agencies to handle the situation." E. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

B. "Mass casualty events do not require an increase in the number of staff needed." C. "A mass casualty event occurs only within the heath care facility and could endanger staff." E. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

A nurse is preparing a presentation on bioterrorism. Which of the following findings should the nurse include as an indication of potential bioterrorism? A. Nationwide incidence of pneumonia is higher than the prior year. B. A large number of otherwise healthy adults are dying from sepsis. C. A health department reports cases of influenza in October. D. Most of the clients diagnosis is with pneumonia have an elevated white blood cell count.

B. A large number of otherwise healthy adults are dying from sepsis.

The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. The nurse diagnoses risk for injury with a goal of keeping the patient safe in the event of a seizure. Which interventions should the nurse utilize for this patient? (Select all that apply.) A. Teach the family how to insert an oral airway during the seizure. B. Assess the home for items that could harm the patient during a seizure. C. Provide information on how to obtain a Medical Alert bracelet. D. Teach the patient to communicate to the caregiver plans for bathing. E. Discuss with family steps to take if the seizure does not discontinue. F. Demonstrate how to restrain the patient in the event of a seizure.

B. Assess the home for items that could harm the patient during a seizure. C. Provide information on how to obtain a Medical Alert bracelet. D. Teach the patient to communicate to the caregiver plans for bathing. E. Discuss with family steps to take if the seizure does not discontinue.

If a nurse applies a restraint vest without the patient's permission or a physician's order, the nurse may be charged with (select all that apply) A. Invasion of privacy B. Battery C. Assault D. Neglect E. False Imprisonment

B. Battery E. False Imprisonment

A nurse manager is developing a safety program for the unit. Which of the following steps should be included during the third step of creating the plan? A. Recognize potential safety hazards. B. Calculate the costs of the plan. C. Assess the amount of risk involved. D. Provide the necessary safety supplies and equipment.

B. Calculate the costs of the plan.

The nurse has been called to a hospital room where a patient is using a hair dryer from home.The patient has received an electrical shock from the dryer. The patient is unconscious and is not breathing. What is the best next step? A. Ask the family to leave the room. B. Check for a pulse. C. Begin compressions. D. Defibrillate the patient.

B. Check for a pulse.

The nurse finds the client sitting on the floor, ensures the client's safety, completes an incident report, and notifies the health care provider of the incident. What should the nurse implement next? A. Staple the incident report in the client's medical record. B. Document the client events and follow-up nursing actions. C. Provide a copy of the incident report to the provider and family. D. Document in the client's medical record that the nurse sent a copy of the report to risk management.

B. Document the client events and follow-up nursing actions.

The student nurse is preparing a list of safety measures for a client who is using oxygen in the home. The registered nurse determines the student needs further teaching if which incorrect measure is placed on the list? A. Stay at least 10 feet away from open flames while using oxygen. B. It is all right to be near someone who is smoking a cigarette while using oxygen. C. Leave a space between the oxygen concentrator and the walls or corners of the room. D. The oxygen should not be turned up without permission from the health care provider.

B. It is all right to be near someone who is smoking a cigarette while using oxygen.

The nurse manager is reviewing with the nursing staff the purposes for applying wrist and ankle restraints to a client. The nurse manager determines that further education is necessary when a nursing staff member states that which is an indication for the use of a restraint? A. Limit movement of a limb. B. Keep the client in bed at night. C. Prevent the violent client from injuring self and others. D. Prevent the client from pulling out intravenous lines and catheters.

B. Keep the client in bed at night.

An elderly patient presents to the hospital with a history of falls, confusion, and stroke. The nurse determines that the patient is at high risk for falls. Which of the following interventions is most appropriate for the nurse to take? A. Place the patient in restraints. B. Lock beds and wheelchairs when transferring .C. Place a bath mat outside the tub. D. Silence fall alert alarm upon request of family

B. Lock beds and wheelchairs when transferring

An automobile accident victim is admitted to the intensive care unit with a medical diagnosis of increased intracranial pressure. What should the nurse do to maintain the client's rights? A. Keep accurate and current medical records. B. Maintain confidentiality and the client's dignity. C. Incorporate available resources in the plan of care. D. Collaborate with other health care team members on discharge planning.

B. Maintain confidentiality and the client's dignity.

A nurse is discussing disaster planning with the board members of a hospital. Which of the following individuals should the nurse expect to request extra supplies and staffing for the facility? A. Incident commander B. Medical command physician C. Triage officer D. Media liaison

B. Medical command physician

Which of the following organizations is primarily responsible for developing and enforcing workplace safety policies? A. National Safety Council (NSC) B. Occupational Safety and Health Administration (OSHA) C. National Institute of Occupational Safety and Health (NIOSH) D. U.S. Department of Health and Human Services

B. Occupational Safety and Health Administration (OSHA)

A client has been placed on contact precautions. What is the appropriate nursing intervention to prevent the spread of infection? A. Restrict all visitors. B. Perform meticulous hand washing frequently. C. Wear a mask and gown for all client contacts. D. Wear sterile gloves for all contacts with the client.

B. Perform meticulous hand washing frequently.

The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint? A. The patient refuses to call for help to go to the bathroom. B. The patient continues to remove the nasogastric tube. C. The patient gets confused regarding the time at night. D. The patient does not sleep and continues to ask for items.

B. The patient continues to remove the nasogastric tube.

When using a fire extinguisher, the hose is aimed at the: A. area around the flame. B. base of the flame. C. middle of the flame. D. top of the flame.

B. base of the flame.

A nurse on a med-surg unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply) A. A client who is dehydrated and receiving IV fluid and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and a blood pressure of 135/85 E. A client who has acute appendicitis and is scheduled for an appendectomy

C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and a blood pressure of 135/85

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water B. Was the affected area with soap C. Brush the chemical off the skin and clothing D. Leave the clothing in place until emergency personnel arrive

C. Brush the chemical off the skin and clothing

A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? A. Give the child milk. B. Give the child syrup of ipecac. C. Call the poison control center. D. Take the child to the emergency department.

C. Call the poison control center.

The nurse reviews wound culture results and learns that an assigned client has methicillin-resistant Staphylococcus aureus (MRSA) in a wound bed. Which type of transmission-based precautions does the nurse institute for this client?A. Enteric precautions B. Droplet precautions C. Contact precautions D. Airborne precautions

C. Contact precautions

A registered nurse (RN) on the night shift assists a staff member in completing an incident report for a client who was found sitting on the floor. Following completion of the report, the RN intervenes if the staff member prepares to take which action? A. Notify the nursing supervisor. B. Ask the unit secretary to telephone the health care provider. C. Document in the nurses' notes that an incident report was filed. D. Forward the incident report to the Continuous Quality Improvement Department.

C. Document in the nurses' notes that an incident report was filed.

A patient is admitted to the unit with an order for seizure precautions. Which action is most appropriate? A. Serve the client's food in paper and plastic containers. B. Ensure that soft limb restraints are applied to upper extremities. C. Maintain the client's bed in the lowest position. D. Move the client to a room closer to the nurses' station.

C. Maintain the client's bed in the lowest position.

A nurse manager of a busy emergency department is working to reduce the potential for violence on the unit. Which of the following will most likely reduce the potential for violence? A. Decrease the number of visible security guards to avoid antagonizing patients. B. Implement procedures to speed up the discharge process for mentally ill patients. C. Propose a plan to expand and update the waiting room. D. Ensure post-assaultive treatment and support is available to all staff.

C. Propose a plan to expand and update the waiting room.

The nurse's first action after discovering an electrical fire in a patient's room is to: A. Activate the fire alarm. B. Confine the fire by closing all doors and windows. C. Remove all patients in immediate danger .D. Extinguish the fire by using the nearest fire extinguisher.

C. Remove all patients in immediate danger

The nurse understands that incident reports allow the agency to analyze adverse client events by which outcome? A. Supplying supervisors with objective information for performance reviews B. Providing a method of reporting injuries to local, state, and federal agencies C. Reviewing quality care and determining potential risks for injury to the client D. Determining the effectiveness of nursing interventions in relation to outcomes

C. Reviewing quality care and determining potential risks for injury to the client

The staff nurse is caring for a client with a head injury who is restless and is pulling at the intravenous line. The client's health care provider does not want to sedate the client, and the family has requested that the client not be restrained. Which is the most appropriate action by the nurse? A. Ask a family member to sit with the client. B. Ask a nursing assistant to monitor the client. C. Stay with the client and consult with the nurse manager about the situation. D. Tell the family that the application of wrist restraints is critical to prevent injury to the client.

C. Stay with the client and consult with the nurse manager about the situation.

During the admission assessment, the nurse assesses the patient for fall risk. Which of thefollowing has the greatest potential to increase the patient's risk for falls? A. The patient is 59 years of age. B. The patient walks 2 miles a day. C. The patient takes Benadryl (diphenhydramine) for allergies. D. The patient recently became widowed

C. The patient takes Benadryl (diphenhydramine) for allergies.

The nurse knows that four categories of risk have been identified in the health care environment. Which of the following provides the best examples of those risks? A. Tile floors, cold food, scratchy linen, and noisy alarms B. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach C. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly D. Dirty floors, hallways blocked, medication room locked, and alarms set

C. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?

Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.

The nurse is providing information regarding safety and accidental poisoning to a grandmother who will be taking custody of a 1-year-old grandchild. Which of the following comments would indicate that the grandmother needs further instruction? A. "The number for poison control is 800-222-1222." B. "Never induce vomiting if my grandchild drinks bleach." C. "I should call 911 if my grandchild loses consciousness." D. "If my grandchild eats a plant, I should provide syrup of ipecac."

D. "If my grandchild eats a plant, I should provide syrup of ipecac."

A community health nurse has provided fire safety instructions to a group of individuals who are part of a disaster response team. Which statement by a group member indicates a need for further instructions? A. "Flames should be doused with water." B. "A blanket or another cover can be used to smother the flames." C. "The victim may be rolled on the ground to extinguish the flames." D. "Keep the victim in a standing position so flames won't spread to the other parts of the body."

D. "Keep the victim in a standing position so flames won't spread to the other parts of the body."

1. A home health nurse is performing a home assessment for safety. Which of the followingcomments by the patient would indicate a need for further education? A. "I will schedule an appointment with a chimney inspector next week." B. "Daylight savings is the time to change batteries on the carbon monoxide detector." C. "If I feel dizzy when using the heater, I need to have it inspected." D. "When it is cold outside in the winter, I can warm my car up in the garage."

D. "When it is cold outside in the winter, I can warm my car up in the garage."

A charge nurse is designating room assignments for clients who will be admitted to the unit. Based onthe nurse's knowledge of fall prevention, which of the following clients should be assigned to the roomclosest to the nurses' station? A. A 43-year-old client who is postoperative following a laparoscopic cholecystectomy B. A 61-year-old client being admitted for telemetry to rule out a myocardial infarction C. A 50-year-old client who is postoperative following an open reduction internal fixation ofthe ankle D. A 79-year-old client who is postoperative following a below-the-knee amputation

D. A 79-year-old client who is postoperative following a below-the-knee amputation

The nurse is presenting an educational session on safety for parents of adolescents. The nurse should include which of the following teaching points? A. Adolescents need unsupervised time with friends two to three times a week. B. Parents and friends should teach adolescents how to drive. C. Adolescents need information about the effects of beer on the liver. D. Adolescents need to be reminded to use seatbelts on long trips

D. Adolescents need to be reminded to use seatbelts on long trips

The nurse sees another nurse administer an incorrect medication to a client. The nurse who administered the incorrect medication does not report the error. Which should be the initial action by the nurse who observed the error?A. Contact the supervisor. B. Complete an incident report. C. Document the error in the client's record. D. Ask the nurse if he or she intends to report the error.

D. Ask the nurse if he or she intends to report the error.

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? A. Home accidents B. Physiological changes of aging C. Poisoning and child abduction D. Automobile accidents, suicide, and substance abuse

D. Automobile accidents, suicide, and substance abuse

Which of the following organizations partners with other agencies in an effort to conduct research and implement prevention strategies to promote safe and healthy work environments? A. The Joint Commission B. American Nurses Association C. Institute of Medicine D. Centers for Disease Control and Prevention

D. Centers for Disease Control and Prevention

A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? A. Begin cardiopulmonary respiration. B. Restrain the child to prevent injury. C. Place a tongue blade over the tongue to prevent aspiration. D. Clear the area around the child to protect the child from injury.

D. Clear the area around the child to protect the child from injury.

The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to A. Learning to walk .B. Trying to pull up on furniture. C. Being dropped by a caregiver. D. Growing ability to explore and oral activity.

D. Growing ability to explore and oral activity.

A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding? A. I will get the caller off the phone as soon as possible so I can alert the staff. B. I will begin evacuating clients using the elevators C. I will not ask any questions and just let the caller talk D. I will listen for background noise

D. I will listen for background noise

The nurse is precepting a student nurse and is careful to check with the student all componentsof the medication process. The nurse explains to the student that most errors occur in A. Ordering and transcribing. B. Dispensing and administering. C. Dispensing and transcribing. D. Ordering and administering

D. Ordering and administering

A patient has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include A. Encouraging visitors in the early evening. B. Placing all four side rails in the "up" position. C. Checking on the patient once a shift. D. Placing a high risk for falls armband on the patient.

D. Placing a high risk for falls armband on the patient.

A 50-year-old blind and deaf patient has been admitted to your floor. As the charge nurse, your primary responsibility for this patient is? A. Let others know about the patient's deficits B. Continuously update the patient on the social environment C. Communicate with your supervisor about your patient safety concerns D. Provide a secure for environment for the patient

D. Provide a secure for environment for the patient

The nurse has been assigned to care for a client recovering at home from a disabling lung infection. While obtaining a nursing history, the nurse learns that the infection is probably the result of human immunodeficiency virus (HIV) contracted through homosexual activity. The nurse is morally opposed to homosexuality and cannot care for the client. The nurse then leaves the client's home. Which is acceptable regarding the nurse's actions? Select all that apply. A. The nurse has the moral right to leave the client's home at any time. B. The nurse has a legal right to inform the client of any barriers to providing care. C. The nurse has a duty to protect self from client care situations that are morally repellent. D. The nurse has a duty to provide competent care to assigned clients in a nondiscriminatory manner. E. The nurse has the right to refuse to care for any client on religious grounds if competent care coverage is arranged.

D. The nurse has a duty to provide competent care to assigned clients in a nondiscriminatory manner. E. The nurse has the right to refuse to care for any client on religious grounds if competent care coverage is arranged.

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 the floors with a bleach solution.