Nokea
After securing the client's safety from a faulty electric bed, the nurse should take which action?
- A. Discuss the matter with the client's significant others.
- B. Document the incident in the client's record in detail.
- C. Notify the physician.
- D. Prepare an incident report.
Correct Answer: D
Rationale: After the situation is safe for the client, the nurse should record the occurrence on an incident form according to the agency protocol.
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The nurse is caring for the client who received afterload internal radiotherapy (brachytherapy) for treatment of uterine cancer. The nurse manager evaluates that the nurse uses correct hazardous material precautions when noting that the nurse takes which action?
- A. Double-bags linens before removing them from the client's room
- B. Minimizes the amount of time spent in contact with the client
- C. Maintains a distance of 1 foot away from the client
- D. Wears lead gloves and apron and a dosimetry badge with client contact
Correct Answer: B
Rationale: Minimizing time spent with the client reduces radiation exposure, a key precaution in brachytherapy.
When an infant car seat is properly installed, the infant should face
- A. forward, so child may look out window
- B. backward, so child faces the seat
- C. the side window, to increase urinary stimulation
- D. upward, as child lies on back with seat installed sideways
Correct Answer: B
Rationale: Infants should be positioned reclining and facing the rear until their leg muscles are strong enough to kick away from the backseat (about 10-12 months-old) for the greatest protection.
The experienced nurse is observing the new nurse providing care to the hospitalized cheat. Which action requires the experienced nurse to intervene to ensure client safety?
- A. Turns on the client's bathroom light and turns out the room lights after settling the client for sleep
- B. Checks the client's room number and name on the name band to verify client identity prior to giving a medication
- C. Stirs thickening powder into the glass of juice and cup of milk before giving these to the client who has dysphagia
- D. Delays the HCP from performing a thoracentesis by calling "a timeout" to verify the client's identity, consent, procedure, and site
Correct Answer: B
Rationale: Room number is not a unique client identifier. The nurse should use two unique identifiers, such as the client's name and medical record number, to verify identity before medication administration.
A newborn has been delivered. An Apgar score is given. What does this scoring system indicate?
- A. heart rate, respiratory effort, color, muscle tone, reflex irritability
- B. heart rate, bleeding, cyanosis, edema
- C. bleeding, reflex, edema
- D. respiratory effort, heart rate, seizures
Correct Answer: A
Rationale: The Apgar scoring system was put into place by Virginia Apgar, an anesthesiologist in New York, for the purpose of assessing newborns in the areas of heart rate, respiratory effort, color, muscle tone, and reflex irritability at 1, 5, and sometimes 10 minutes after birth.
The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of safe, proficient nursing practice?
- A. Verify the order for the medication. Prior to giving the medication the nurse should say, 'Please state your name.'
- B. Upon entering the room the nurse should ask: 'What is your name? What allergies do you have?' and then check the client's name band and allergy band.
- C. As the room is entered say 'What is your name?' then check the client's name band.
- D. Verify the client's allergies on the chart and confirm the client's name on the name band.
Correct Answer: B
Rationale: Asking the client to state their name and allergies, then verifying with the name band and allergy band, ensures accurate identification and safety.