HURST Fundamental QBank Exam, Most Recent Exam
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A client admitted to a long-term care facility is legally blind
and partially deaf. How would the nurse best provide for
the client's safety in the event of an emergency?
Select all that apply
1. Have roommate lead client out of the room to safety
area.
2. Assign a specific UAP every shift to escort client to
safety.
3. Research established protocols utilized by emergency
groups.
4. Discuss best communication methods with client and
family.
5. Plan for the supervisor to be responsible for evacuating
the client. - Answers-3 & 4. Correct: When faced with a
new or challenging situation involving client safety, the
nurse manager should employ the Nursing Process to
assess needs and collect contributing data. Asking for
input from emergency preparedness groups, such as the
Red Cross or FEMA, could provide ideas about assisting
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individuals with sensory deficits. Secondly, the nurse
should discuss the situation with both client and family to
determine appropriate methods of communicating with
client, particularly in an emergency situation.
1. Incorrect: The responsibility for client safety should
never be placed on a roommate or even family members.
Staff should be accountable for client safety at all times.
2. Incorrect: Assigning a specific UAP each shift to locate
and escort client to a safe area would be confusing.
Changing protocols every shift creates a hazardous
situation for staff and clients.
5. Incorrect: The facility supervisor is responsible for all
aspects of an emergency, including activation of alarms,
coordinating evacuation of staff and clients, and initiating
facility emergency protocols such as closing fire doors or
turning off oxygen valves. It would not be safe for the
supervisor to also be responsible for a single individual.
A client is brought to the emergency room following a
serious motor vehicle accident. Standing orders include
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initiating an IV line and inserting a foley catheter. What
action should the nurse take first?
1. Obtain all supplies for the procedures.
2. Explain the procedure to the client.
3. Check the client's identification band.
4. Verify client has signed consent forms. - Answers-3.
Correct: Even in an emergency, the nurse follows the
nursing process by initially gathering data, including
identifying the client before beginning any ordered
interventions. The client's identity must always be verified
before any procedure or treatment.
1. Incorrect: It is important to make sure all necessary
supplies are present before beginning an intervention.
Stopping in the middle of a procedure to get supplies
could expose the client to infection or other complications.
However, gathering supplies is an action, which is not the
first step when providing care to any client.
2. Incorrect: While it is important to explain any procedure
to the client, the scenario does not indicate if this client is
even conscious. The nurse has another important priority.
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4. Incorrect: When stabilizing an injured client, consent is
implied for life-saving procedures such as initiating an IV
or applying oxygen. Additionally, obtaining or verifying
consent is not a nursing responsibility.
The nurse notices the primary healthcare provider
removes gloves after performing an invasive procedure on
a client. The healthcare provider then enters another
client's room without washing hands. What is the initial
action by the nurse?
1. Ignore it since the primary healthcare provider knows
best.
2. Contact the nursing supervisor.
3. Notify the chief of medical staff.
4. Remind the primary healthcare provider of the
importance of standard precautions. - Answers-4. Correct:
The nurse is the client's advocate and can remind the
primary healthcare provider of the importance of washing
hands before entering a client's room. Hand washing
should be performed when going from one room to
another.
1. Incorrect: Nurses are to be client advocates and resolve
a problem that they see. The primary healthcare provider