1. A nurse sees smoke emerging from the suction equip- 3. Protect the clients
ment being used. Which is the greatest priority in the
event of a fire?
1. Report the fire
2. Extinguish the fire
3. Protect the clients
4. Contain the fire
2. A nurse who is teaching a group of adult ages 20-40 1. Automobile crashes
years old about safety is going to ensure that which
topic is priority?
1. Automobile crashes
2. Drowning and firearms
3. Falls
4. Suicide and homicide
3. An 87-year-old man is admitted to the hospital for 3. Provide a bedside com-
cellulitis of the left arm. He ambulates with a walker mode
and takes diuretic medication to control symptoms of
fluid retention. Which intervention is most important
to protect him from injury?
1. Leave the bathroom light on
2. Withhold the client's diuretic medication
3. Provide a bedside commode
4. Keep the siderails up
4. A mother and her 3-year-old live in a home built in 3. Risk for poisoning
1932. Which NANDA nursing diagnosis is most applic-
able for this child?
1. Risk for suffocation
2. Risk for injury
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3. Risk for poisoning
4. Risk for Disuse Syndrome
5. A 75-year-old client, hospitalized with a cerebrovas- 4. Use a bed exit safety
cular accident (stroke), becomes disoriented at times monitoring device
and tries to get out of bed, but is unable to ambulate
without help. What is the most appropriate safety mea-
sure?
1. Restrain the client to the bed
2. Ask a family member to stay with the client
3. Check the client every 15 minutes
4. Use a bed exit safety monitoring device
6. A client is being admitted to the hospital because of 2 and 5
a seizure that occurred at his home. The client has
no previous history of seizures. In planning the clients
nursing care, which of the following measures is most
essential at this time of admission? Select all that ap-
ply
1. Place a padded tongue depressor at the head of the
bed
2. Pad the bed with blankets
3. Inform the client about the importance of wearing a
medical identification tag
4. Teach the client about epilepsy
Test oral suction equipment
7. Which nursing intervention is the highest in priority of 4. Place the bed in the
the client t risk for falls in a hospital setting? Lowest position
1. Keep all the side rails up
2. Review prescribed medications
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3. Complete the "get up and go" test
4. Place the bed in the lowest position
8. Medication errors can place the client at significant 3,4, and 5
risk. Which practice(s) will help decrease the possibility
of errors? Select all that apply
1. Hire only competent nurses
2. Improve the nurses ability to multitask
3. Establish a reporting system for "near misses"
4. Communicate effectively
5. Create a culture of trust
9. When planning to teach health care topics to a group 3. Guns are the most fre-
of male adolescents, which topic should the nurse con- quent used weapons for
sider a priority? adolescent suicide.
1. Sports contribute to an adolescent's self-esteem
2. Sunbathing and tanning beds can be dangerous
3. Guns are the most frequent used weapons for ado-
lescent suicide.
4. A drivers education course is mandatory for safety
10. The nurse, at change-of-shift report, learns that one of 1,3,4, and 5
the clients in his care has bilateral soft wrist restraints.
The client is confused, is trying to get out of bed, and
has pulled out the IV line, which was subsequently
reinserted. Which actions by the nurse is appropriate?
Select all that apply
1. Document the behavior(s) that require continued
used of the restraints
2. Ensure that the restraints are tied to the side rails
3. Provide range-of-motion exercises when the re-
straints are removed