NURSING 2362 MODULE 6 EXAM |2022 EXAM PACK

NURSING 2362 MODULE 6 EXAM Questions 1. ID: 9Which event would require a nurse to complete and file an incident report? A client has a seizure. The nurse determines that a client would benefit from the use of a walker to ambulate. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. 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. Test-Taking 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 Giddens Concepts: Clinical Judgment, Health Policy HESI Concepts: Clinical Decision-Making/Clinical Judgment, Health Policy/Systems Awarded 1.0 points out of 1.0 possible points. 2. ID: 5A 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? Notifying the nursing supervisor Tearing up and discarding the incident report Telling the physician that the error warrants the completion of an incident report Correct 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 follow-through with an incident report. Therefore, the other options are incorrect. Test-Taking 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 Giddens Concepts: Clinical Judgment, Health Policy HESI Concepts: Clinical Decision-Making/Clinical Judgment, Health Policy/Systems Awarded 1.0 points out of 1.0 possible points. 3. ID: 5Contact precautions are initiated for a client with methicillin- resistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant: To transfer the client to a semiprivate room That gloves only are needed to care for the client To wear gloves and a gown when changing the client's bed linen. Correct 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. Test-Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed-ended 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 (7th ed., 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 Giddens Concepts: Infection, Leadership HESI Concepts: Collaboration/Managing Care—Leadership, Infection Awarded 1.0 points out of 1.0 possible points. 4. ID: 1The mother of a 3-year-old 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: Call a poison control center Correct Administer an excessive amount of fluids to induce vomiting Call an ambulance to bring the child to the emergency department 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 mother should then call an ambulance. Test-Taking 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). Maternal- child 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 Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 1.0 points out of 1.0 possible points. 5. ID: 0A 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? Activating the agency disaster plan Correct Supplying the triage rooms with additional equipment Increasing the number of nursing staff for the day on which the hurricane is expected 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. Test-Taking 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 with this question. Reference: Black, J., & Hawks, J. (2009). Medical-surgical 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 Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 1.0 points out of 1.0 possible points. 6. ID: 3A 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. “I need to follow the oxygen prescription exactly.” Correct “I can use my electric razor while I’m using oxygen.” “I have to keep the oxygen concentrator out of direct sunlight.” Correct “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” “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. Test-Taking 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 Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Client Education Awarded 3.0 points out of 3.0 possible points. 7. ID: 7A 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: Every 2 hours Correct Every 3 hours Every 4 hours 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. Test-Taking 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 (7th ed., p. 837). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Giddens Concepts: Leadership, Safety HESI Concepts: Collaboration/Managing Care—Leadership, Safety Awarded 1.0 points out of 1.0 possible points. 8. ID: 3A 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: Implementing a child safety program Planning a focused child safety program Performing an analysis of health problems related to child safety 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. Test-Taking 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 Giddens Concepts: Family Dynamics, Safety HESI Concepts: Family Dynamics, Safety Awarded 1.0 points out of 1.0 possible points. 9. ID: 3The 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? An incident report was completed and filed. Ramipril (Altace) 2.5 mg was administered at 9 am. Correct Twice the amount of the prescribed ramipril was administered at 9 am. Client’s blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril. Rationale: After an incident, the nurse would document a concise and objective description of what occurred and any follow-up actions taken in the client’s record. The nurse would not document in the client’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. Test-Taking Strategy: Focus on the data in the question. Recall that notes made in a client’s record must be objective. Eliminate the options that are comparable or alike in that they indicate that an incorrect dose of medication was administered. Next note that the correct option clearly and accurately describes the incident in an objective manner. Review documentation of a medication error or other incident if you had difficulty with this question. References: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 557, 558). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 704, 705). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal Giddens Concepts: Health Policy, Technology and Informatics HESI Concepts: Health Policy/Systems, Informatics/Technology Awarded 1.0 points out of 1.0 possible points. 10. ID: 9A home health nurse has been called to the home of an older postoperative cardiovascular 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? The client’s bed is in a low position. The client is oriented to person, place, and time. The caregiver uses the overbed table for feedings. The caregiver leaves both siderails down while the client is in bed. Correct Rationale: Leaving the siderails of older client’s bed down may increase the client’s risk of falling. The aging process also increases this client’s potential for falls; therefore, evaluating the safety of the environment is a necessity. Keeping the client’s bed in a low position, orientating the client to the environment, and using the overbed table for feedings are all ways to help ensure the client’s safety. Test-Taking Strategy: Use the process of elimination, focusing on the subject, a observation of an unsafe practice. Noting that the question indicates that the bed is in the low position and that the client is oriented will assist you in eliminating these options. To select from the remaining options, choose the one that identifies an unsafe practice. Review the causes of falls in an older client if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 329). St. Louis: Mosby. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Safety Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Client Education Awarded 1.0 points out of 1.0 possible points. 11. ID: 5A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. Skin Correct Lungs Correct Immune Urinary Lymphatic Gastrointestinal Correct Rationale: Anthrax, caused by Bacillus anthracis, can be contracted through the gastrointestinal system, abrasions in the skin, or inhalation. It is not contracted through the immune system, urinary tract, or lymphatic system. Test-Taking Strategy: Specific knowledge of the routes of infection with B. anthracis is needed to answer this question. Remember that anthrax can be contracted through the gastrointestinal system, skin, or lungs. Review content on anthrax and its modes of transmission if you had difficulty with this question. Reference: McEwen, M., & Pullis, B. (2009). Community-based nursing: An introduction (3rd ed., p. 410). Philadelphia: Saunders. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Biological/chemical warfare Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Client Education Awarded 2.0 points out of 3.0 possible points. 12. ID: 3A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin’s disease. Which precaution should the nurse take while working with this intravenous (IV) infusion? Wearing gloves and a mask Wearing gloves and a gown Wearing gloves, a mask, and eye protection Correct Wearing gloves, a mask, and a head covering Rationale: When handling chemotherapeutic agents, the nurse should wear disposable latex gloves, a mask that covers the nose and mouth, and eye protection, especially if a biological hood is not available. Wearing gloves and a mask or gloves and a gown will not provide adequate protection. A head covering is not necessary. Test-Taking Strategy: Knowledge regarding the precautions for handling chemotherapeutic agents is necessary to answer this question. Think about the effects and cytotoxic nature of chemotherapy to answer the question. Select the option that will provide the greatest degree of protection to the nurse handling chemotherapeutic agents. If you had difficulty with this question, review the precautions for preparing a chemotherapy infusion. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 423). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 1.0 points out of 1.0 possible points. 13. ID: 5A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the IV tubing port to the solution bag, the tubing drops, hitting the top of the medication cart. Which action should the nurse take to maintain asepsis? Obtaining new IV tubing Correct Obtaining a new IV solution bag Scrubbing the tubing port with an alcohol swab Wiping the tubing port with povidone-iodine solution (Betadine) Rationale: If IV tubing becomes contaminated as a result of coming into contact with some nonsterile object, the nurse should obtain new IV tubing. Contaminated tubing could cause systemic infection in the client. The IV solution bag has not been contaminated and does not need replacement. Wiping the tubing port with Betadine or scrubbing it with alcohol is insufficient and would be contraindicated regardless, because the tubing will be attached directly to a catheter in the client’s vein. Test-Taking Strategy: Visualize the situation as you read the question. Use your knowledge of basic infection control measures and IV therapy to answer this question. Also, focus on the data in the question and note that the IV tubing has become contaminated. Review aseptic technique if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., pp. 179, 188). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Giddens Concepts: Infection , Safety HESI Concepts: Infection, Safety Awarded 1.0 points out of 1.0 possible points. 14.ID: 7A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home? Staying secluded in the bedroom Wearing an oxygen mask at all times Keeping the house closed up to minimize the spread of disease Disposing of contaminated tissues in a container with a leak-proof bag Correct Rationale: The client under respiratory precautions at home does not need to remain secluded; the client would not be at home if he or she were infectious. However, proper respiratory precautions are necessary. The house should be properly ventilated, and the windows should be opened as much as possible. Wearing an oxygen mask at all times is not a respiratory precaution, and there is no information in the question to indicate that oxygen is necessary. Contaminated tissues should be discarded in container with a leak-proof bag and then placed in an outdoor trash bin. Tissues should not be left lying around. Test-Taking Strategy: Use the process of elimination. Focus on the client’s diagnosis and the subject, respiratory precautions at home. Recalling the mode of transmission and home care measures for TB will direct you to the correct option. Also note the words “secluded,” “all times,” and “closed up” in the incorrect options. If you had difficulty answering this question, review the precautions that should be taken by the client with TB who has been discharged home. Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 670). St. Louis: Saunders. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Infection Control Giddens Concepts: Infection , Safety HESI Concepts: Infection, Safety Awarded 1.0 points out of 1.0 possible points. 15.ID: 5A home health nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicate a need for further teaching? Select all that apply. “I need to use night lights.” “I need to remove my wall-to-wall carpeting.” Correct “I need to get handrails put up in the bathroom.” “I need to use the staircase handrails when I go up the stairs.” “I should walk barefoot as much as possible so that I’ll know about any wet spots on the floor.” Correct Rationale: Home modifications to reduce the risk of falls include ensuring ample lighting, removing scatter rugs, placing handrails in bathrooms, and using handrails on all staircases. The client should wear flat rubber-soled shoes to prevent slips and falls. Walking barefoot will not reduce the risk of injury; in fact, it could actually increase the risk of foot injury and of slipping and falling. Removal of wall-to-wall carpeting is not necessary. Test-Taking Strategy: Note the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect options. Answer this question by eliminating the options that involve providing physical support for the client and that you know are needed in this situation (e.g., night lights, handrails). Review home care measures to ensure safety and prevent falls if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 1062). St. Louis: Mosby. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Giddens Concepts: Client Education , Safety HESI Concepts: Safety, Teaching and Learning/Client Education Awarded 2.0 points out of 2.0 possible points. 16.ID: 7A nurse caring for a client who is under airborne precautions notes that the client is scheduled for a nuclear scan. Which action on the part of the nurse is appropriate? Planning to have the nuclear scan performed at the bedside Asking the technicians in the nuclear scan department to wear masks Placing a surgical mask on the client for transport and for contact with other individuals Correct Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued Rationale: If the client is under airborne precautions, client movement and transport should be limited as much as possible. If transport or movement is necessary, the nurse can minimize the dispersal of droplet nuclei from the client by placing a surgical mask on the client. Having the scan performed at the bedside is unreasonable. Asking the technicians in the nuclear medicine department to wear masks would not prevent the dispersal of droplet nuclei from the client. The physician is the individual who would prescribe the cancellation or delay of a diagnostic test. Additionally, delaying the test until airborne precautions have been discontinued is not within the role of the nurse. Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, airborne precautions. Knowing that a nurse should not delay a prescribed test will help you eliminate this option. Eliminate the option of having the scan at the bedside, because this action is unreasonable. To select from the remaining options, recall the route and mode of transmission of an airborne infection. This should direct you to the correct option. Review airborne precautions if you had difficulty with this question. Reference: Ackley, B., Ladwig, G., Swan, B., & Tucker, S. (2008). Evidence- based nursing care guidelines: Medical-surgical interventions (p. 475). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Giddens Concepts: Infection , Safety HESI Concepts: Infection, Safety Awarded 1.0 points out of 1.0 possible points. 17.ID: 6A nurse employed in a physician’s office hears a client in the waiting room call out, “Help! Fire!” The nurse rushes to the waiting room and finds that the wastebasket is on fire. The nurse immediately: Confines the fire Extinguishes the fire Activates the fire alarm Removes the clients from the waiting room Correct Rationale: The immediate priority in the event of a fire is removing any clients in immediate danger. The next step is activating the fire alarm. The nurse would then confine the fire by closing all of the doors and, finally, extinguish the fire. Test-Taking Strategy: Remember the mnemonic RACE to prioritize actions in the event of a fire: Rescue clients in immediate danger, sound the alarm, confine the fire by closing all doors, and extinguish. If you had difficulty with this question, review the principles of fire safety. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7the ed., pp. 839, 840). St. Louis: Mosby. 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. 18. ID: 3A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first? Confining the fire Extinguishing the fire Activating the fire alarm Correct Running for the fire extinguisher Rationale: The immediate priority in the event of a fire is rescuing the clients in immediate danger. In this situation, no clients are in immediate danger. The next step is to activate the fire alarm. The nurse then confines the fire by closing all doors and, finally, extinguishes the fire. Test-Taking Strategy: Use the mnemonic RACE to remember priorities in the event of a fire: rescue clients in immediate danger, sound the alarm, confine the fire by closing all doors, and extinguish. If you had difficulty with this question, review the principles of fire safety. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 840). St. Louis: Mosby. 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. 19. ID: 5The safety department is providing a yearly educational session on fire safety and the use of fire extinguishers. A nurse is asked to demonstrate the use of a fire extinguisher after the session. The nurse demonstrates appropriate use of the fire extinguisher by first: Aiming at the base of the fire Pulling the pin on the fire extinguisher Correct Squeezing the handle of the extinguisher Sweeping from the top to the bottom of the fire with the extinguisher Rationale: To use a fire extinguisher, pull the pin first. Next, aim the extinguisher at the base of the fire. Squeeze the handle of the extinguisher, then extinguish the fire by sweeping from side to side to coat the area evenly. Test-Taking Strategy: Use the mnemonic PASS to remember the steps in the use of a fire extinguisher: Pull the pin, aim at the base of the fire, squeeze the handle, and sweep from side to side to coat the area evenly. If you had difficulty with this question, review the appropriate use of a fire extinguisher. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 840, 841). St. Louis: Mosby. 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. 20.ID: 1A nurse provides instruction to a new nursing assistant regarding the application of a restraint to a client. The nurse watches as the nursing assistant applies the restraint. What observation tells the nurse that the nursing assistant is using correct procedure? The assistant applies a tie knot in the restraint strap. The assistant attaches the restraint straps securely to the siderails. The assistant applies the restraint so that the strap does not tighten when force is applied against it. Correct The assistant secures the restraint in such a way that it is impossible to slip a finger between the restraint and the client’s skin. Rationale: A half-bow or safety knot should be used to apply a restraint, because it does not tighten when force is applied against it and because it allows quick, easy removal of the restraint in the event of an emergency. The restraint strap is secured to the bed frame, never to the side rails, to help prevent accidental injury in the event that the siderail is released. A restraint should be secured in such a way that one or two fingers can be easily slipped between the restraint and the client’s skin. Test-Taking Strategy: Note the strategic words “correct procedure” in the query. This indicates that you are looking for an option that involves an accurate measure of how a restraint is applied. Use the process of elimination and your knowledge of safety measures and the use of restraints to answer the question. Noting the words “tie knot,” “siderails,” and “impossible to slip” will assist you in eliminating these options. Review guidelines for the application of restraints if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 337). St. Louis: Mosby. Cognitive Ability: Evaluating 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. 21.ID: 5