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The nurse manager is reviewing a list of serious reportable events that occurred in a hospital setting before submitting the list to an external agency. Which event should the nurse manager remove from the list before it is submitted?
- A. The nurse is seriously injured when touching the client during a cardioversion procedure.
- B. The client obtains a skin tear and abrasion while transferring from the bed to a wheelchair.
- C. The client has a hip fracture after wandering off the unit and falling down the stairs.
- D. The client has a cardiac arrest; the serum potassium level was low and not reported to the HCP.
Correct Answer: B
Rationale: A skin tear and abrasion are not considered serious reportable events, unlike the other options which involve serious injuries or failures.
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Which of the following microorganisms are considered normal body flora?
- A. staphylococcus on the skin
- B. streptococcus in the nares
- C. candida albicans in the vagina
- D. pseudomonas in the blood
Correct Answer: A
Rationale: Of the choices given, only staphylococcus is considered a normal resident of the body.
The nurse is caring for clients in a hospital setting. Which observations made by the nurse require intervention? Select all that apply.
- A. The client's infusion pump is noted to have a cut in the center of the cord.
- B. The client's bed is in the high position after a nursing assistant left the room.
- C. The client's battery-operated CD player does not have an agency inspection tag.
- D. The client's bed exit alarm is beeping, and another nurse just left the room.
- E. The client's bedside table is placed in front of the chair where the client is sitting.
Correct Answer: A,B,D
Rationale: A: A cut cord poses an electrical shock risk. B: A high bed increases fall risk. D: A beeping bed exit alarm indicates a potential fall risk requiring immediate response.
A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?
- A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves shaving her legs.'
- B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
- C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'
- D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'
Correct Answer: C
Rationale: Patient confidentiality should be observed, especially in public places. The nurse should tell the nursing student do not discuss confidential information in public.
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (ALS). Which of these pieces of equipment is the priority for the client to have access to in the home?
- A. A wheelchair
- B. A hospital bed with trapeze
- C. A communication board
- D. A suction machine
Correct Answer: C
Rationale: In late-stage ALS, clients often lose the ability to speak due to muscle weakness. A communication board is critical to ensure the client can express needs and maintain communication.
Which of the following statements describes the purpose of client restraint?
- A. Restraints are a nursing measure used to maintain client control.
- B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
- C. Restraints are a therapeutic measure designed to positively reinforce client behavior.
- D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.
Correct Answer: B
Rationale: The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physician's order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider.