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NURSING 2362 MODULE 6 EXAM

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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

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NURSING 2362 MODULE 6 EXAM
Questions
1. ID: 8482541809Which 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: 8482539805A 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: 8482539895Contact 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

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