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The nurse is teaching a group of students on incident reports. Which of the following situations would require an incident report? Select all that apply.
- A. Requesting to view their medical record.
- B. Complaining about poor care from a nurse.
- C. Leaving against medical advice (AMA).
- D. Requesting an increase in pain medication.
- E. Threatening a nurse with bodily harm.
Correct Answer: B,C,E
Rationale: Complaints about care, AMA, and threats require incident reports to document potential risks or issues. Viewing records and requesting medication changes do not.
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The charge nurse is reviewing room assignments and recognizes that only one private room is left. It would be appropriate to assign this room to the client with
- A. Human immunodeficiency virus (HIV).
- B. Delirium tremens who is agitated.
- C. Disseminated herpes zoster.
- D. An implantable port that is accessed.
Correct Answer: C
Rationale: Disseminated herpes zoster requires airborne and contact precautions, necessitating a private room. HIV, delirium tremens, and accessed ports do not require isolation.
The nurse is conducting a staff education program on managing chemotherapy spills. Which actions should the nurse recommend be taken in the event of a chemotherapy spill? Select all that apply.
- A. Contain the spill using plastic-backed absorbent sheets or spill pads.
- B. Wear sterile gloves when cleaning the spill.
- C. Immediately remove any contaminated clothing and wash the affected skin with soap and water.
- D. Research the appropriate cleaning agent based on the spilled drug.
- E. Leave the spill area unattended until a supervisor arrives.
- F. Implement airborne precautions after the spill has been cleaned.
Correct Answer: A,C
Rationale: Containing the spill and decontaminating skin/clothes are critical. Sterile gloves are unnecessary, researching during a spill delays action, leaving unattended is unsafe, and airborne precautions are irrelevant.
A client is rushed to the emergency department after exposure to radioactive materials in a workplace accident. The client's supervisor phoned ahead and informed the charge nurse of the chemical with which the client came in contact. What should be the initial action of the nurse?
- A. Remove all the client's clothing and decontaminate the client.
- B. Ask the client what happened during the accident.
- C. Decontaminate the room where the client was staying.
- D. Save the clothing for analysis.
Correct Answer: A
Rationale: Removing clothing and decontaminating the client is the initial action to minimize radiation exposure.
The nurse supervises a student nurse auscultating lung sounds on a group of clients. Which statement by the student nurse would require follow-up?
- A. Wheezes arise from the small airways and usually do not clear with coughing.
- B. A pleural friction rub causes loud, rough, scratching sounds usually during inspiration.
- C. Thick, tenacious secretions that clear with coughing cause crackles.
- D. Fluid or secretions in large airways typically cause coarse crackles.
Correct Answer: C
Rationale: Crackles are caused by air moving through fluid in small airways and do not typically clear with coughing. Other statements are accurate.
The nurse supervises a student assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse
- A. Puts the client's affected (weaker) arm in the shirt's sleeve first.
- B. Places shoes with velcro straps on the client's feet.
- C. Places the wheelchair as close to the bed as possible on the client's affected (weaker) side.
- D. Places the hairbrush in the client's unaffected (stronger) hand.
Correct Answer: C
Rationale: Wheelchair on the affected side hinders transfer; it should be on the unaffected side. Dressing the weaker arm first, velcro shoes, and stronger hand use are correct.