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A nurse is observing an AP administer 0.9% sodium chloride enema to an adult client. For
which of the following actions by the AP should the nurse intervene?
a. Positions the client on her left side with knees flexed
b. Administers the solution at room temp
c. Points tubing in the direction of the umbilicus during insertion
d. Inserts the tubing 8cm (3.1 in) into the rectum
Correct Answer:
a. Positions the client on her left side with knees flexed
A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following
statements by the newly licensed nurse indicates an understanding of the teaching?
a. "I should encrypt personal health information when sending emails."
b. "I can post the client's vital signs in the client's room."
c. "I can use another nurse's password as long as I log off after using the computer"
d. "I should discard personal health information documents in the trash before leaving the
unit"
Correct Answer:
a. "I should encrypt personal health information when sending emails."
,A nurse is participating on a committee that is considering the creation of a policy that will
allow the nurses to remove chest tubes. Which of the following is an appropriate resource for
the nurse to consult in planning for this policy?
a. ANA Standards of Practice
b. ANA Code of Ethics
c. State Nurse Practice Act
d. Institute of medicine
Correct Answer:
c. State Nurse Practice Act
A charge nurse observes a licensed practical nurse tell a client that she will return with a
medication to help relieve the client's nausea. The LPN does not return with the medication.
The charge nurse should reinforce which of the following ethical principles with the LPN?
a. Veracity
b. Justice
c. Fidelity
d. Nonmaleficence
Correct Answer:
c. Fidelity
A nurse administrator is using benchmarking as control criteria while reviewing current
policies and &procedures. Which of the following actions should the nurse take?
a. Use root cause analysis to identify gaps in meeting standards
b. Establish work initiatives to promote a positive environment
c. Compare practices within the facility against other high-performing facilities
d. Determine how current practice will affect future performance within the facility
, Correct Answer:
c. Compare practices within the facility against other high-performing facilities
A nurse enters a client's room and identifies that the client is receiving too much IV fluid
because the IV pump is not working properly. Which of the following actions should the nurse
take first?
a. Place a faulty equipment tag on the pump
b. Notify the provider
c. Auscultate the client's lungs
d. Complete an incident report
Correct Answer:
c. Auscultate the client's lungs
A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the
surgical suite. Which of the following nursing statements is an appropriate nursing response?
a. "It's not too late to cancel the surgery if you want to"
b. "Why did you make the decision to have this procedure?"
c. "This won't take long and it will be over before you know it"
d. "You shouldn't be worried because the procedure is very safe"
Correct Answer:
a. "It's not too late to cancel the surgery if you want to"
A facility infection control nurse is reviewing the reports of a group of clients. Which of the
following infections should the nurse report to the public health department?
a. Lyme disease