Nokea
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client receives burns from a heating pad.
- B. A client reports being dissatisfied with the temperature of the meals provided.
- C. A client becomes disoriented and falls out of bed.
- D. A client’s visitor becomes dizzy and faints in the client's room.
- E. A client is unable to afford the physical therapy that the provider recommends.
Correct Answer: A,C,D
Rationale: A: Injury requires reporting. C: Fall indicates safety issue. D: Visitor incident needs documentation.
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A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?
- A. Clean the hearing aid with isopropyl alcohol.
- B. Turn the hearing aid off for 5 minutes.
- C. Soak the hearing aid in warm water.
- D. Decrease the volume on the hearing aid.
Correct Answer: D
Rationale: Decreasing volume reduces feedback causing the whistling sound.
A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?
- A. Isopropyl alcohol.
- B. Hydrogen peroxide.
- C. Chlorhexidine gluconate.
- D. Chlorine bleach.
Correct Answer: D
Rationale: Chlorine bleach effectively kills bloodborne pathogens like HIV and hepatitis B.
A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?
- A. I think about my grandfather's farm to reduce pain.
- B. I listen to my favorite music to take my mind off the pain.
- C. I use focused breathing to control my pain.
- D. I learn to notice the sensation of muscle tension.
Correct Answer: A
Rationale: Guided imagery involves visualizing a calming scene like a farm to distract from pain, reducing stress and perception of discomfort.
A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?
- A. Clean the hearing aid with isopropyl alcohol.
- B. Turn the hearing aid off for 5 minutes.
- C. Soak the hearing aid in warm water.
- D. Decrease the volume on the hearing aid.
Correct Answer: D
Rationale: Lowering volume addresses feedback, a common cause of whistling.
A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the specimen in a clean specimen cup.
- B. Remove 45 mL of urine from the catheter with a syringe.
- C. Clamp the catheter tubing below the needleless port.
- D. Clamp the catheter tubing for 60 min.
Correct Answer: C
Rationale: Clamping below the port ensures a fresh, uncontaminated sample.