Nokea
The client is expressing suicidal ideations.
A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?
- A. Do you have a plan for harming yourself?
- B. Has anyone in your family ever died by suicide?
- C. Do you have someone to discuss your feelings with?
- D. Can you tell me about the stresses in your life?
Correct Answer: A
Rationale: Assessing a plan determines immediate risk, the priority in suicide assessment.
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A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply)
- A. Instruct another nurse to record the prescription in the medical record.
- B. Ask the provider to spell out the name of the medication.
- C. Withhold the medication until the provider signs the prescription.
- D. Record the date and time of the telephone prescription.
- E. Request that the provider confirm the read-back of the prescription.
Correct Answer: B,D,E
Rationale: Spelling the medication, recording date/time, and confirming read-back ensure accuracy and safety.
A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. Droplet precautions require that I wear a gown and gloves when providing client care.
- B. Following a blood spill, I should use a bleach solution with a ratio of 1 to 20.
- C. Soiled dressings should be placed in a biohazard trash receptacle.
- D. For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub.
Correct Answer: C
Rationale: Soiled dressings in biohazard receptacles prevent infection spread, showing understanding.
A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?
- A. Release the client's restraints every 4 hr.
- B. Check the client's status every hour.
- C. Obtain written consent by the client for the placement of the restraints.
- D. Document the client's behavior leading to the initiation of the restraints.
Correct Answer: D
Rationale: Documenting behavior justifies restraint use and meets legal standards.
A nurse is assisting with teaching a class about the importance of fire safety. Which of the following hazards should the nurse include as an example of the leading cause of residential fires?
- A. Placing a space heater 5 ft from bed
- B. Smoking in bed
- C. Leaving the stove on
- D. Lack of smoke detectors
Correct Answer: B
Rationale: Smoking in bed is a leading cause of residential fires.
A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Measure the duration of the seizure
- B. Restrain the client's arms and legs to prevent injury
- C. Lower the side rails of the bed when the seizure begins
- D. Insert an oral airway into the client's mouth
Correct Answer: A
Rationale: Measuring duration aids in assessing seizure severity and planning care.