nur 115 exam 3
a nurse is caring for a client with rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. the nurse should initiate a referral with which of the following interprofessional health care team?
Occupational Therapist
While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?
Wash the site of injury with soap and water
A nurse in a clinic is caring for a client who reports pain, crepitus and a popping sound in his temporomandibular joint. Based on these findings, to which of the following providers should the nurse request a referral for the client?
oral surgeon
A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom."After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record?
"The provider was notified."
a nurse is teaching the family of a client who has a new diagnosis of epilepsy about the actions to take if the client experiences a seizure. which of the following instructions should the nurse include in the teaching?
"move objects away from the client"
A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?
Assess the client.
a charge nurse is discussing disaster response with the nursing staff. which of the following statements indicate an understanding of the hospital incident command system (HICS)?
HICS identities facility responsibilities and channels of reporting
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?
Lock the wheels of the bed and the wheelchair.
An older adult client who lives alone tells a clinic nurse that he is unable to drive himself to the store and is afraid to cook on the stove. Which of the following community resources should the nurse recommend for this client?
Meals on Wheels
A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster?
Nurses and other emergency medical personnel
A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care?
Obtain IV access
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
Secure the restraints using a quick-release tie.
a nurse is caring for an older adult client who states, "I am afraid I may fall while walking to the bathroom during the night," which of the following actions should the nurse take?
leave a nightlight on in the clients room
A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear whensetting up the client's meal tray?
mask
a nurse in working with an interdisciplinary disaster committee to develop a community wide emergency response plan in the event of a nonbiological or chemical incident. the nurse should include which of the following agencies to be notified immediately after 911?
office of emergency management (OEM)
a nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of med admin 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 med admin error
a nurse preparing to transfer a client who has left-sided weakness from the bed to a chair. which of the following actions should the nurse plan to take?
use a gait belt to stand and pivot the client
a nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. which of the following actions should the nurse take to maintain safety during the transfer?
use powered standing-assist lift
a home health nurse is conducting a home safety assessment for an older adult client. which of the following findings should the nurse identify as a safety risk for the client?
water temp of 130*F throw rugs
A nurse is among the first responders to a mass-casualty incident and does not know what type of personal protective equipment (PPE) is needed. Which of the following actions should the nurse take?
Choose the highest level of protection equipment available.
A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?
Compare the number of medications before and after the action was implemented.
A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"I will place a bath seat in my shower to use when I bathe"
a nurse is caring for several clients. for which of the following incidents should the nurse complete an incident report?
a client discovers his dentures are missing
A nurse is teaching a group of newly hired nurses about the requirements for disaster planning. Which of the following statements by one of the newly hired nurses indicates an understanding of the teaching?
"Disaster drills should be held on a regular basis."
A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?
"I will begin upon the client's admission to the facility."
A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
A client who has severe respiratory stridor and a deviated trachea
A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take?
Check on the client hourly. Instruct the client in the use of the call light. Apply an ambulation alarm to the client's leg.
A nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which of the following statements by the newly licensednurse indicates understanding of the teaching?
I should encourage clients to receive an annual flu immunization
A charge nurse is discussing staff nurses' responsibilities in preplanning for response to a disaster. Which of the following responsibilities should the nurse include in the discussion?
Identifying community resources that are available.
A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actionsis the nurse's priority?
Move any clients in the immediate vicinity
A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?
Move the client to a room closer to the nurses' station.
A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following actions should the nurse take?
Place a yellow tag on the client's upper body.
A\a nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. which of the following interventions should the nurse include?
Provide a suction setup at the bedside Elevate the side rails near the head when the client is in bed Place the bed in the lowest position Keep an oxygen setup at the bedside
A nurse is reviewing incident reports submitted during the previous month. The nurse should identify which of the following as a problem that should be reported to the risk manager?
Reports routinely omit the names of witnesses to the occurrence.
A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of thefollowing is most important for the nurse to determine?
The client's current weight-bearing status
a nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?
The client's hand is cool and pale
A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?
The service began with the client's admission to the hospital
A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Turn the client's head to the side
a nurse is performing triage for a group of clients following a mass casualty incident (MCI). which of the following clients should the nurse plan to care for first?
a client experiencing tension pneumothorax
a nurse is helping triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. which of the following clients should the nurse tag as priority for care?
a client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site
a nurse is the triage officer in the ED when four clients arrive following a factory explosion. which of the following clients should the nurse care for first?
an unconscious adult client who has a sucking chest wound, RR 38/min, cap refill <2 secs
a nurse is caring for a child who is having a seizure which of the following actions should the nurse take?
assess the patency of the clients airway remove objects away from clients place client in side-lying position
a nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. which of the following instructions should the nurse include?
bend at the knees when picking up an object
a nurse finds that the client did nit not receive the scheduled dose of furosemide (Lasix). which of the following should the nurse include in the incident/ variance report?
date of incident time pt was supposed to receive the med pt VS
a nurse is working with a limited staff because of a severe storm in the area. the facility incident commander has initiated disaster protocols. which of the following actions should the nurse take
focus on providing care that prevents life-threatening emergencies
A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident reportabout the pressure ulcer, the nurse should take which of the following actions?
include any relevant statements the client made about the ulcer
a nurse is triaging victims of a multiple motor-vehicle crash. the assesses a client trapped under a car who is apneic and has a weak pulse at 120/min after repositioning his upper airway, the client remains apneic. which of the following actions should the nurse take?
place a black tag on the client's upper body and attempt to help the next client in need
a nurse enters a client's room and finds the client in the floor having a seizure. which of the following actions should the nurse take?
place the client on his side
a nurse is caring for a child having tonic-clonic seizures and vomiting. which of the following is the nurses priority?
position the client side lying
a nurse is caring for a child who is experiencing a seizure. which of the following actions should the nurse take?
position the pt. laterally
a nurse is assessing a client following a natural disaster who is experiencing difficulty sleeping due to nightmares, feelings of survivor guilt, and difficulty concentrating. which of the following diagnoses describe the client's symptoms?
post traumatic stress syndrome
a nurse in an acute care setting is serving on a committee whose charge is to use the auditing process to client care. which of the following aspects of client care is measured by a process audit?
quality of nursing care provided
clients are panicking and the room is filling with smoke. indicate the emergency actions the nurse must take
remove the clients from the room activate the fire alarm close the door extinguish the fire
place the steps in order in which they should be performed in the case of a fire emergency.
rescue the clients pull the fire alarm confine the fire extinguish the fire
a nurse is discussing the use of mechanical restraints with a newly licensed nurse. which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?
self- destructive behavior despite alternative interventions
a nurse is caring for a client who is experiencing dysphagia. the nurse should recommend a referral to which of the following members of the health care team
speech therapist
a nurse is caring for a client who falls in his room. after the nurse assesses the client, notifies the clients provider, and completes an incident report, which of the following actions should the nurse take?
submit the incident report to the risk manager
a nurse is caring for a client who is at risk for falls. which of the following actions should the nurse take?
teach pt to use call light bed in the lowest position fall risk band on pt
a nurse is preparing an inservice presentation for a group of newly licensed nurses about the use of restraints. which of the following should the nurse include as a criterion for applying restraints?
the nurse has already considered alternatives for restraints
a nurse at an extended care facility is instructing a class of APs about client use of assistive devices during ambulation. which of the following instructions should the nurse give the APs about the clients use of a cane?
they should move the cane forward first
