Module 6 Exam
Questions
1. 1.ID: 327496299
Which of the following events would require a nurse to complete and file an incident report?
A. A client
... [Show More] has a seizure.
B. The nurse determines that a 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. Correct
Rationale: An incident is any event that is not consistent with the routine operation of a healthcare
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 omission of prescribed
therapies, and circumstances leading to injury or a risk for injury. An 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 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 functioning pump and send the nonfunctioning pump
to the appropriate department for repair.
TestTaking Strategy: Use the process of elimination and read each option carefully. Recalling that
an incident is any event that is not consistent with the routine operation of a healthcare unit or
routine care of a client will direct you to the correct option. Review the reasons for filing an incident
report if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 336, 337, 403). St.
Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 327496839A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol
(Tenormin) was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the
client’s vital signs, completes an incident report, and calls the physician to report the error. The
physician 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 physician that the error warrants the completion of an incident
report Correct
D. Telling the nursing supervisor that the physician did not want an incident report
completed and filed
Rationale: Incident reports are an important part of a healthcare agency’s quality improvement
program. An incident is any event that is not consistent with the routine operation of a healthcare 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 completed and
filed in accordance with agency guidelines. The nursing supervisor would be notified of the incident;
however, on the basis of the data in the question, the nurse should tell the physician that the error
warrants completion and followthrough with an incident report. Therefore, the other options are
incorrect.
TestTaking Strategy: Focus on the subject of the question, the physician’s telling the nurse that an
incident report is not needed. Eliminate the options that are comparable or alike in that they involve
notifying the nursing supervisor. To select from the remaining options, recall the purpose of an
incident report to select the correct option. Review the procedures involved in completing and filing
incident reports if you had difficulty with this question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 557, 558). St.
Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 327496835Contact precautions are initiated for a client with methicillinresistant Staphylococcus aureus (MRSA)
infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the
assistant:
A. To transfer the client to a semiprivate room
B. That gloves only are needed to care for the client
C. To wear gloves and a gown when changing the client's bed linen. Correct
D. To wear a gown when caring for the client and remove the gown immediately
after leaving the client’s room
Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client contact is
anticipated. Goggles are worn to protect the mucous membranes of the eye during interventions that
may produce splashes of blood or body fluids, secretions, or excretions. The client should be placed
in a private room or, if a private room is not 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 before leaving the client’s room.
TestTaking Strategy: Use the process of elimination. Eliminate the option that includes the closedended word “only.” Next eliminate the option that involves removal of the gown after leaving the
client’s room. To 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 had difficulty with
this question, review contact precautions.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 655, 663). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 327496225
A nurse hears someone calling, “Help! My bed is on fire!” On entering the room, the nurse finds a
client trying to beat out the flames with a pillow. Place in order of priority the actions that the nurse
should take:
Correct
A. Removing the client from the room
B. Pulling the nearest fire alarmC. Closing the door to the room
D. Running to get the nearest fire extinguisher
Rationale: A nurse who encounters a fire emergency should think of the mnemonic RACE. The first
step is to remove the client from the room, after which the nurse should activate the fire
alarm, contain the fire, and extinguish the fire. This is a universal standard that may be applied to
any type of fire emergency. Removing the client from the room is the first step. Pulling the nearest
fire alarm is the second step (alarm). Closing the door to the room to contain the fire is the third
action. Obtaining the nearest fire extinguisher to put out the fire is the fourth action.
TestTaking Strategy: Focus on the subject, the steps to take in a fire emergency. With this in mind,
sequence the actions, using the RACE mnemonic. Review fire safety if you had difficulty with this
question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 839, 840). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
2. 5.ID: 327495383
The mother of a 3yearold calls a neighbor who is a nurse and reports that her child just drank some
window cleaner that had been stored in a cabinet. The nurse should instruct the mother to
immediately:
A. Call a poison control center Correct
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 physician answering service about the incident
Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting 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 healthcare provider has given
specific instructions to induce vomiting. Neither calling an ambulance nor calling the physician’s
answering service is the immediate action, because either would delay treatment. Additionally, the
physician would immediately make a referral to the poison control center. The poison control center
may advise the mother to bring the child to the emergency department; if this is the case, the mothershould then call an ambulance.
TestTaking Strategy: Note 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
eliminate the option that involves inducing vomiting. Next eliminate 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 difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternalchild
nursing (3rd ed., pp. 120, 121). St. Louis: Elsevier.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
B. 6.ID: 327495361
A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an
area hospital is advised to prepare for causalities. Which action should the nurse manager who
receives the telephone call regarding this warning take first?
A. Activating the agency disaster plan Correct
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
Rationale: In an external disaster, many people may be brought to the emergency department for
treatment. Although increasing the nursing staff and supplying the triage rooms with 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 secure the building
from the storm is not a responsibility that falls within the scope of nursing management.
TestTaking Strategy: Note 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 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 if you had difficulty withthis question.
Reference: Black, J., & Hawks, J. (2009). Medicalsurgical nursing: Clinical management for positive
outcomes (8th ed., pp. 76, 2213, 2214). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Disasters
Awarded 1.0 points out of 1.0 possible points.
C. 7.ID: 327496843
A home health nurse has instructed a client about safety measures during the use of an oxygen
concentrator in the home. Which statement by the client indicates to the nurse that the client has
understood the directions? Select all that apply.
A. “I need to follow the oxygen prescription exactly.” Correct
B. “I can use my electric razor while I’m using oxygen.”
C. “I have to keep the oxygen concentrator out of direct sunlight.” Correct
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.” Correct
Rationale: The client should follow the oxygen prescription exactly. 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 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. 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 physician, nurse, and oxygen vendor available and teaching the client signs and
symptoms requiring emergency care.
TestTaking Strategy: 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 options that are unsafe. Review oxygen safety measures if you had difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 631). St.
Louis: Mosby.Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
D. 8.ID: 327495381
A nurse is providing instructions to a nursing assistant who will be caring for a client in hand
restraints. The nurse instructs the nursing assistant to release the restraints to permit muscle
exercise:
A. Every 2 hours Correct
B. Every 3 hours
C. Every 4 hours
D. Every 30 minutes
Rationale: The nurse should instruct the nursing assistant to assess the restraints and the client’s
circulatory status and skin 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 always be followed.
TestTaking Strategy: Knowledge regarding the use of restraints is necessary 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 difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 837). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
E. 9.ID: 327496271A community health nurse working in a school setting is concerned because parents are not
participating in health activities designed to promote child safety. In this situation, the
most appropriate initial action is:
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 Correct
Rationale: 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.
TestTaking Strategy: Use the steps of the nursing process to answer the question. Note that the
correct option involves the process of assessment, the first step of the nursing process. Review the
procedure for planning health activities to provide safety if you had difficulty with this question.
Reference: Maurer, F., & Smith, C. (2009). Community/public health nursing practices: Health for
families and populations (4th ed., p. 445). Philadelphia: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
F. 10.ID: 327496807
The nurse administers a dose of ramipril (Altace) 2.5 mg to a client at 9 am. While documenting
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 physician 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 am. Correct
C. Twice the amount of the prescribed ramipril was administered at 9 am.
D. Client’s blood pressure was 128/82 mm Hg after the administration of the
incorrect dose of ramipril [Show Less]