Which event would require a nurse to complete and file an incident report? ID: 18630127828
A. A client has a seizure.
B. The nurse determines that a
... [Show More] client would benefit from the use of a walker to ambulate.
C. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump
is not working.
D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor’s blood pressure and
takes the visitor to the emergency department for treatment. C Co or rr re ec ct t
Rationale: Rationale: An An incident is any event that is not consistent with the routine operation of a health incident is any event that is not consistent with the routine operation of a health
care unit or routine care of a client. Examples of incidents include client falls, needlestick care unit or routine care of a client. Examples of incidents include client falls, needlestick
injuries, a visitor having symptoms of illness, medication administration errors, accidental injuries, a visitor having symptoms of illness, medication administration errors, accidental
omission of prescribed therapies, and circumstances leading to injury or a risk for injury omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An . An
incident report does not need to be filed if a client has a seizure unless the client sustains injury incident report does not need to be filed if a client has a seizure unless the client sustains injury
as a result of the seizure. If the nurse determines that a client would benefit from the use of a as a result of the seizure. If the nurse determines that a client would benefit from the use of a
walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse
notes that the battery of an intravenous infusion pump is not working, he or she should obtain a notes that the battery of an intravenous infusion pump is not working, he or she should obtain a
functioning pump and send the nonfunctioning pump to the appropriate department for repair functioning pump and send the nonfunctioning pump to the appropriate department for repair. .
T Test-T est-Taking Strategy: aking Strategy: Use Use knowledge of the subject, reasons for filing an incident report, to knowledge of the subject, reasons for filing an incident report, to
assist you with the process of elimination. Read each option carefully assist you with the process of elimination. Read each option carefully. Recalling that an incident . Recalling that an incident
is any event that is not consistent with the routine operation of a health care unit or routine care is any event that is not consistent with the routine operation of a health care unit or routine care
of a client will direct you to the correct option. Review the reasons for filing an incident report if of a client will direct you to the correct option. Review the reasons for filing an incident report if
you had dif you had difficulty with this question. ficulty with this question.
Cognitive Ability: Cognitive Ability: Applying Applying
Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Ethical/Legal Ethical/Legal
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
1.A nurse, charting the administration of medications to an assigned client at 9 p.m., notes that ID: 18630128204
atenolol (Tenormin) was prescribed to be administered at 9 a.m. instead of 9 p.m. The nurse checks the client’s
vital signs, completes an incident report, and calls the health care provider to report the error. The health care
provider tells the nurse that an incident report is not needed but instructs her to monitor the client during the
night for hypotension. What action should the nurse take?
A. Notifying the nursing supervisor
B. Tearing up and discarding the incident report
C. Telling the health care provider that the error warrants the completion of an incident report C Co or rr re ec ct t
Rationale: Rationale: Incident Incident reports are an important part of a health care agency’ reports are an important part of a health care agency’s quality improvement s quality improvement
program. An incident is any event that is not consistent with the routine operation of a health program. An incident is any event that is not consistent with the routine operation of a health
care unit or routine care of a client. An example of an incident is administering a medication at a care unit or routine care of a client. An example of an incident is administering a medication at a
time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is
completed and filed in accordance with agency guidelines. The nursing supervisor would be completed and filed in accordance with agency guidelines. The nursing supervisor would be
notified of the incident; however notified of the incident; however, on the basis of the data in the question, the nurse should tell , on the basis of the data in the question, the nurse should tell
the health care provider that the error warrants completion and follow-through with an incident the health care provider that the error warrants completion and follow-through with an incident
report. Therefore, the other options are incorrect. report. Therefore, the other options are incorrect.
T Test-T est-Taking Strategy: aking Strategy: Focus Focus on the subject of the question, the health care provider on the subject of the question, the health care provider’’s telling the s telling the
nurse that an incident report is not needed. Eliminate the comparable or alike options that nurse that an incident report is not needed. Eliminate the comparable or alike options that
involve notifying the nursing supervisor involve notifying the nursing supervisor. T . To select from the remaining options, recall the purpose o select from the remaining options, recall the purpose
of an incident report to select the correct option. Review the procedures involved in completing of an incident report to select the correct option. Review the procedures involved in completing
and filing incident reports if you had dif and filing incident reports if you had difficulty with this question. ficulty with this question.
Cognitive Ability: Cognitive Ability: Applying Applying
Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Ethical/Legal Ethical/Legal
D. Telling the nursing supervisor that the health care provider did not want an incident report completed
and filed
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
2.
Contact precautions are initiated for a client with methicillin-resistant Staphylococcus ID: 18630127846
aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client,
tells the assistant to take which action?
A. To transfer the client to a semiprivate room
B. That gloves only are needed to care for the client
3.C.
To wear gloves and a gown when changing the client’s bed linen
C Co or rr re ec ct t
Rationale: Rationale: Contact Contact precautions require the use of gloves, gown, and goggles if direct client precautions require the use of gloves, gown, and goggles if direct client
contact is anticipated. The client should be placed in a private room or contact is anticipated. The client should be placed in a private room or, if a private room is not , if a private room is not
available, in a semiprivate room with another client who has active infection with the same available, in a semiprivate room with another client who has active infection with the same
microorganism but no other infection. The nursing assistant would remove the protective gear microorganism but no other infection. The nursing assistant would remove the protective gear
before leaving the client’ before leaving the client’s room. s room.
T Test-T est-Taking Strategy: aking Strategy: Use Use the process of elimination. Eliminate the option that includes the the process of elimination. Eliminate the option that includes the
closed-ended word “only closed-ended word “only.” Next eliminate the option that involves removal of the gown after .” Next eliminate the option that involves removal of the gown after
leaving the client’ leaving the client’s room. T s room. To select from the remaining options, read each carefully and visualize o select from the remaining options, read each carefully and visualize
the procedure instituted for contact precautions, which will direct you to the correct option. If you the procedure instituted for contact precautions, which will direct you to the correct option. If you
had dif had difficulty with this question, review contact precautions. ficulty with this question, review contact precautions.
Cognitive Ability: Cognitive Ability: Applying Applying
Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment
Integrated Process: Integrated Process: T Teaching and Learning eaching and Learning
Content Area: Content Area: Leadership/Management Leadership/Management
D. To wear a gown when caring for the client and remove the gown immediately after leaving the client
s room
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank ID: 18630127871
some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately
take which action?
A. Call a poison control center. C Co or rr re ec ct t
Rationale: Rationale: When a When a poisoning occurs, a poison center should be called immediately poisoning occurs, a poison center should be called immediately. V . Vomiting omiting
should not be induced if the victim is unconscious or if the substance ingested was a strong should not be induced if the victim is unconscious or if the substance ingested was a strong
corrosive or petroleum product. Also, vomiting should not be induced unless a health care corrosive or petroleum product. Also, vomiting should not be induced unless a health care
provider has given specific instructions to induce vomiting. Neither calling an ambulance nor provider has given specific instructions to induce vomiting. Neither calling an ambulance nor
calling the health care provider calling the health care provider’’s answering service is the immediate action, because either s answering service is the immediate action, because either
would delay treatment. Additionally would delay treatment. Additionally, the health care provider would immediately make a referral , the health care provider would immediately make a referral
to the poison control center to the poison control center. The poison control center may advise the mother to bring the child . The poison control center may advise the mother to bring the child
to the emergency department; if this is the case, the mother should then call an ambulance. to the emergency department; if this is the case, the mother should then call an ambulance.
T Test-T est-Taking Strategy: aking Strategy: Note Note the strategic word “immediately” in the query of the question. First, the strategic word “immediately” in the query of the question. First,
recalling that vomiting should not be induced without appropriate advice to do so will help you recalling that vomiting should not be induced without appropriate advice to do so will help you
4.eliminate the option that involves inducing vomiting. Next eliminate the comparable or alike eliminate the option that involves inducing vomiting. Next eliminate the comparable or alike
options that will delay treatment (i.e., calling an ambulance and leaving a message with the options that will delay treatment (i.e., calling an ambulance and leaving a message with the
answering service). Review immediate poison control measures if you had dif answering service). Review immediate poison control measures if you had difficulty with this ficulty with this
question. question.
Cognitive Ability: Cognitive Ability: Applying Applying
Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Safety Safety
B. Administer an excessive amount of fluids to induce vomiting.
C. Call an ambulance to bring the child to the emergency department.
D. Leave a message at the health care provider answering service about the incident.
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department ID: 18630128240
of an area hospital is advised to prepare for casualties. Which action should the nurse who receives the
telephone call regarding this warning take first?
A. Activating the agency disaster plan C Co or rr re ec ct t
Rationale: Rationale: In In an external disaster an external disaster, many people may be brought to the emergency department , many people may be brought to the emergency department
for treatment. Although increasing the nursing staf for treatment. Although increasing the nursing staff and supplying the triage rooms with f and supplying the triage rooms with
additional equipment may be steps in preparing for casualties, the initial action by the nurse additional equipment may be steps in preparing for casualties, the initial action by the nurse
manager must be activation of the disaster plan. Calling the hospital maintenance department to manager must be activation of the disaster plan. Calling the hospital maintenance department to
secure the building from the storm is not a responsibility that falls within the scope of nursing secure the building from the storm is not a responsibility that falls within the scope of nursing
management. management.
T Test-T est-Taking Strategy: aking Strategy: Note Note the strategic word “first” in the query of the question. Use the the strategic word “first” in the query of the question. Use the
process of elimination in determining the priority action. Note that the correct option is the process of elimination in determining the priority action. Note that the correct option is the
umbrella option. Also remember that other necessary activities will be initiated once the agency umbrella option. Also remember that other necessary activities will be initiated once the agency
disaster plan has been activated. Review procedures related to management in times of disaster plan has been activated. Review procedures related to management in times of
disaster if you had dif disaster if you had difficulty with this question. ficulty with this question.
Cognitive Ability: Cognitive Ability: Applying Applying
Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Disasters Disasters
5.B. Supplying the triage rooms with additional equipment
C. Increasing the number of nursing staff for the day on which the hurricane is expected
D. Calling the hospital maintenance department to secure the building against the storm
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
A home health nurse has instructed a client about safety measures during the use of an ID: 18630128283
oxygen concentrator in the home. Which statements by the client indicate to the nurse that the client has
understood the directions? Select all that apply.
A. “I need to follow the oxygen prescription exactly.” C Co or rr re ec ct t
B. “I can use my electric razor while I’m using oxygen.”
C. “I have to keep the oxygen concentrator out of direct sunlight.” C Co or rr re ec ct t
D. “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.”
E. “I have to tell everyone that they can’t smoke or have an open flame within 10 feet of the oxygen
concentrator.” C Co or rr re ec ct t
Rationale: Rationale: The The client should follow the oxygen prescription exactly client should follow the oxygen prescription exactly. The use of electric razors or other . The use of electric razors or other
equipment that could emit sparks should be avoided while oxygen is in use, because fire and injury to equipment that could emit sparks should be avoided while oxygen is in use, because fire and injury to
the client could result. The oxygen concentrator is kept out of direct sunlight and slightly away from the client could result. The oxygen concentrator is kept out of direct sunlight and slightly away from
walls and corners to permit adequate air flow walls and corners to permit adequate air flow. The client should not allow smoking or any type of flame . The client should not allow smoking or any type of flame
within 10 feet of the oxygen source. Other measures include having telephone numbers for the health within 10 feet of the oxygen source. Other measures include having telephone numbers for the health
care provider care provider, nurse, and oxygen vendor available and teaching the client signs and symptoms , nurse, and oxygen vendor available and teaching the client signs and symptoms
requiring emergency care. requiring emergency care.
T Test-T est-Taking Strategy: aking Strategy: Recall Recall knowledge of the subject, oxygen safety measures, to assist you with knowledge of the subject, oxygen safety measures, to assist you with
eliminating options. Recall that one hazard associated with oxygen is ignition, which could result from eliminating options. Recall that one hazard associated with oxygen is ignition, which could result from
heat in the form of flames or sparks. Evaluating the question from this perspective, eliminate the heat in the form of flames or sparks. Evaluating the question from this perspective, eliminate the
options that are unsafe. Review oxygen safety measures if you had dif options that are unsafe. Review oxygen safety measures if you had difficulty with this question. ficulty with this question.
Cognitive Ability: Cognitive Ability: Evaluating Evaluating
Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment
Integrated Process: Integrated Process: Nursing Process/Evaluation Nursing Process/Evaluation
Content Area: Content Area: Safety Safety
A Awarded 3.0 points out of 3.0 possible points. warded 3.0 points out of 3.0 possible points.
6.
A nurse is providing instructions to a nursing student who will be caring for a client in hand ID: 18630128226
restraints. The nurse instructs the nursing student to release the restraints to permit muscle exercise how
7.frequently?
A. Every 2 hours C Co or rr re ec ct t
Rationale: Rationale: The The nurse should assess the restraints and the client’ nurse should assess the restraints and the client’s circulatory status and skin s circulatory status and skin
integrity every 30 minutes. Restraints must be released at least every 2 hours to permit muscle integrity every 30 minutes. Restraints must be released at least every 2 hours to permit muscle
exercise and promote circulation. Agency guidelines regarding the use of restraints should exercise and promote circulation. Agency guidelines regarding the use of restraints should
always be followed. always be followed.
T Test-T est-Taking Strategy: aking Strategy: Knowledge Knowledge regarding the subject, the use of restraints, is necessary to regarding the subject, the use of restraints, is necessary to
answer this question. Noting the strategic words “release the restraints” will help direct you to answer this question. Noting the strategic words “release the restraints” will help direct you to
the correct option. Review nursing responsibilities regarding the use of restraints if you had the correct option. Review nursing responsibilities regarding the use of restraints if you had
dif difficulty with this question. ficulty with this question.
Cognitive Ability: Cognitive Ability: Applying Applying
Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment
Integrated Process: Integrated Process: T Teaching and Learning eaching and Learning
Content Area: Content Area: Safety Safety
B. Every 3 hours
C. Every 4 hours
D. Every 30 minutes
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
A community health nurse working in a school setting is concerned because parents are not ID: 18630128238
participating in health activities designed to promote child safety. In this situation, which is the most appropriate
initial action?
A. Implementing a child safety program
B. Planning a focused child safety program
C. Performing an analysis of health problems related to child safety
D. Determining the appropriateness of the planned health activity C Co or rr re ec ct t
Rationale: Rationale: In this situation, the best initial action would be to determine the appropriateness of In this situation, the best initial action would be to determine the appropriateness of
the planned health activities. This would be followed by analysis, planning, and implementation. the planned health activities. This would be followed by analysis, planning, and implementation.
T Test-T est-Taking Strategy: aking Strategy: Use Use the steps of the nursing process to answer the question. Note that the the steps of the nursing process to answer the question. Note that the
correct option involves the process of data collection, the first step of the nursing process. correct option involves the process of data collection, the first step of the nursing process.
Review the procedure for planning health activities to provide safety if you had dif Review the procedure for planning health activities to provide safety if you had difficulty with this ficulty with this
question. question.
8.Cognitive Ability: Cognitive Ability: Applying Applying
Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Safety Safety
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
The nurse administers a dose of ramipril 2.5 mg to a client at 9 a.m. While documenting ID: 18630123889
administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The
nurse assesses the client, completes an incident report, and notifies the health care provider and nursing
supervisor of the error. What statement does the nurse add to the client’s record?
A. An incident report was completed and filed.
B. Ramipril (Altace) 2.5 mg was administered at 9 a.m. C Co or rr re ec ct t
Rationale: Rationale: After After an incident, the nurse would document a concise and objective description of an incident, the nurse would document a concise and objective description of
what occurred and any follow-up actions taken in the client’ what occurred and any follow-up actions taken in the client’s record. The nurse would not s record. The nurse would not
document in the client’ document in the client’s record that an incident report was completed. Nor would the nurse s record that an incident report was completed. Nor would the nurse
document that twice the prescribed dose was given or that an incorrect dose was given. document that twice the prescribed dose was given or that an incorrect dose was given.
T Test-T est-Taking Strategy: aking Strategy: Focus Focus on the data in the question. Recall that notes made in a client’ on the data in the question. Recall that notes made in a client’s s
record must be objective. Eliminate the comparable or alike options that indicate that an record must be objective. Eliminate the comparable or alike options that indicate that an
incorrect dose of medication was administered. Next note that the correct option clearly and incorrect dose of medication was administered. Next note that the correct option clearly and
accurately describes the incident in an objective manner accurately describes the incident in an objective manner. Review documentation of a medication . Review documentation of a medication
error or other incident if you had dif error or other incident if you had difficulty with this question. ficulty with this question.
Cognitive Ability: Cognitive Ability: Applying Applying
Client Needs: Client Needs: Safe and Ef Safe and Effective Care Environment fective Care Environment
Integrated Process: Integrated Process: Communication and Documentation Communication and Documentation
Content Area: Content Area: Ethical/Legal Ethical/Legal
C. Twice the amount of the prescribed ramipril was administered at 9 a.m.
D. Client’s blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril.
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
9.A home health nurse has been called to the home of an older postoperative cardiovascular ID: 18630127884
client by the client’s son. The son tells the nurse, “We’re using a hospital bed here at home, but my mother has
fallen out of bed three times.” Which observation by the nurse reflects an increased risk of this client’s falling out
of bed?
A. The client’s bed is in a low position.
B. The client is oriented to person, place, and time.
C. The caregiver uses the overbed table for feedings.
D. The caregiver leaves both siderails down while the client is in bed [Show Less]