1. The nurse enters the patient’s room and notices a small fire in the headlight
above the patient’s bed. In which order will the nurse perform the steps,
beginning with the first one?
1. Pull the alarm.
2. Remove the patient.
3. Use the fire extinguisher.
4. Close doors and windows.
a. 2, 1, 4, 3
b. 1, 2, 4, 3
c. 1, 2, 3, 4
d. 2, 1, 3, 4
ANS: A
Nurses use the mnemonic RACE to set priorities in case of fire. The steps are as
follows: Rescue and remove all patients in immediate danger; Activate the alarm;
Confine the fire by closing doors and windows; and Extinguish the fire using an
appropriate extinguisher.
31. The nurse is providing information regarding safety and accidental
poisoning to a grandparent who will be taking custody of a 1-year-old grandchild.
Which comment by the grandparent will cause the nurse to intervene?
a. “The number for poison control is 800-222-1222.”
b. “Never induce vomiting if my grandchild drinks bleach.”
c. “I should call 911 if my grandchild loses consciousness.”
d. “If my grandchild eats a plant, I should provide syrup of ipecac.”
ANS: D
The administration of ipecac syrup or induction of vomiting is no longer
recommended for routine home treatment of poisoning. The nurse must intervene
to provide additional teaching. All the rest are correct and do not require follow up.
The poison control number is 800-222-1222. After a caustic substance such as
bleach has been drunk, do not induce vomiting. This can cause further burning and
,injury as the substance is eliminated. Loss of consciousness associated with
poisoning requires calling 911.
32. A home health nurse is assessing a family’s home after the birth of an
infant. A toddler also lives in the home. Which finding will cause the nurse to
follow up?
a. Plastic grocery bags are neatly stored under the counter.
b. Electric outlets are covered in all rooms.
c. No bumper pads are in the crib.
d. Crib slats are 5 cm apart.
ANS: A
Plastic grocery bags increase the risk for suffocation. The nurse will follow up
with instructions to remove or keep locked or out of reach. All the rest are correct
and do not require follow-up. Electrical outlets should be covered to reduce
electrical shock. Bumper pads are not used in the crib to prevent suffocation,
strangulation, or entrapment. Crib slats should be less than 6 cm apart.
33. Which patient will the nurse see first?
a. A 56-year-old patient with oxygen with a lighter on the bedside table
A 56-year-old patient with oxygen using an electric razor for
b. grooming
A 1-month-old infant looking at a shiny, round battery just out of
c. arm’s reach
A 1-month-old infant with a pacifier that has no string around the
d. baby’s neck
ANS: B
The nurse will see the patient shaving with an electric razor first as this is an actual
problem. Do not use oxygen around electrical equipment or flammable products. A
lighter on the bedside table and a shiny, round battery are potential problems, not
actual. Plus, it would be hard, almost impossible, for a 1 month old to actually grab
the battery when it is out of arm’s reach. A baby should use a pacifier without
strings.
34. A home health nurse is teaching a family to prevent electrical shock.
Which information will the nurse include in the teaching session?
a. Run wires under the carpet.
, b. Disconnect items before cleaning.
c. Grasp the cord when unplugging items.
d. Use masking tape to secure cords to the floor.
ANS: B
A guideline to prevent electrical shock is to disconnect items before cleaning.
Do not run wires under carpeting. Grasp the plug, not the cord, when
unplugging items. Use electrical tape to secure the cord to the floor, preferably
against baseboards.
35. The nurse has placed a yellow armband on a 70-year-old patient. Which
observation by the nurse will indicate the patient has an understanding of this
action?
a. The patient removes the armband to bathe.
b. The patient wears the red nonslip footwear.
c. The patient insists on taking a “water” pill in the evening.
The patient who is allergic to penicillin asks the name of a new
d. medicine.
ANS: B
A yellow armband is an alert for high risk of falls. Red nonslip footwear helps to
grip the floor and decreases the chance of falling. The communication armband
should stay in place and should not be removed, so that all
members of the interdisciplinary team have the information about the high risk for
falls. A red armband indicates an allergy. Give diuretics (“water” pill) in the
morning to decrease risk of falls during the night— when most falls occur.
36. An older-adult patient is using a wheelchair to attend a physical therapy
session. Which action by the nurse indicates safe transport of the patient?
a. Positions patient’s buttocks close to the front of wheelchair seat
b. Backs wheelchair into elevator, leading with large rear wheels first
c. Places locked wheelchair on same side of
bed as patient’s weaker side Unlocks
wheelchair for easy maneuverability when
patient is
d. transferring
ANS: B