ANSWERS SURE A+
✔✔A nurse is reviewing the medication administration record of a client and notes that
the client received an incorrect dose of medication. After ensuring that the client is safe,
which of the following actions should the nurse take? - ✔✔Complete an incident report
about the medication error.
Once the nurse ensures the client is safe, the nurse who discovered the error should
complete an incident report in a timely manner. An incident report allows the facility to
analyze collected information to improve client safety and prevent future errors.
✔✔A nurse is preparing assignments for the upcoming shift. Which of the following
tasks should the nurse delegate to an assistive personnel (AP)? - ✔✔Obtain a
scheduled blood glucose reading is stable.
The nurse should assign the AP to obtain a scheduled blood glucose reading on a
stable client. This task is within the range of function for an AP. However, if a client's
condition is unstable, a licensed nurse should obtain the client's blood glucose reading.
✔✔A nurse is delegating a task to an assistive personnel (AP). The AP states he is
unsure about performing the task. Which of the following actions should the nurse take
first? - ✔✔Determine the AP's level knowledge about the task
, The first action the nurse should use when using the nursing process is to collect data
from the AP to determine their level of knowledge of the task.
✔✔A nurse is contributing to the plan of care for a client who has heart failure. The
client has been instructed to limit their sodium and fluid intake. Which of the following
referrals should the nurse suggest? - ✔✔Dietitian
The nurse should suggest a referral for a dietitian who is specialized to consult the client
about low-sodium food selections and fluid restrictions.
✔✔A nurse is assisting with admitting a client who has cystic fibrosis. For which of the
following health care team members should the nurse anticipate a referral? -
✔✔Respiratory therapist
Respiratory therapists can assist clients who have breathing problems and disorders,
such as cystic fibrosis, They also conduct pulmonary function tests and help clients
manage oxygen therapy equipment.
✔✔A nurse is caring for a client who has tested positive for vancomycin-resistant
enterococci of the urine. Which of the following actions by the nurse demonstrates an
understanding of infection control? - ✔✔Bagging soiled linens before exiting the client's
room
The nurse should bag the client's soiled linens before exiting the client's room to prevent
accidental exposure and contamination to other clients or personnel.
✔✔A nurse is caring for a client who has a facial injury. The client tells the nurse that
the injury was a result of partner violence. After treating the client's physical injury,
which of the following actions should the nurse take next? - ✔✔Take photos of the
client's injuries.
Accurate documentation of the client's injuries in the medical record can provide
valuable evidence in the event future legal action is taken against the The first action
the nurse should take using the nursing process is to collect data from the client by
documenting and taking photos of the client's injuries. perpetrator.
✔✔A home health nurse is visiting a client who has a new diagnosis of Parkinson's
disease. Which of the following findings should the nurse plan to address first? - ✔✔The
client's medications are missing.
The greatest risk to this client is injury from interruption in the client's medication
regimen. Abrupt withdrawal from some medications can cause severe adverse effects.
Therefore, the priority finding for the nurse to address is the client's missing
medications.