38 practice questions – Flashcards
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1. The nurse has investigated safety hazards and recognizes that which one of the following statements is accurate regarding safety needs? 1. Bacterial contamination of foods is uncontrollable. 2. Fire is the greatest cause of unintentional death. 3. Carbon dioxide levels should be monitored in home settings. 4. Temperature extremes seldom affect the safety of clients in acute care facilities.
answer
Carbon dioxide levels should be monitored in home settings.
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2. An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is: 1. Confusion 2. Impaired judgment 3. Sensory deficits 4. History of falls
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History of falls
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3. An inservice program is being offered in the hospital on bioterrorism and the response of the health care agency. During the program, the mitigation phase is described. The nurse is informed that this phase includes: 1. Determination of hazard vulnerability and the impact of the emergency situation 2. Steps taken to manage the effects of the event and an inventory of available resources 3. Steps taken by staff to triage victims 4. Restoration of essential services
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Determination of hazard vulnerability and the impact of the emergency situation
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4. An inservice program is being offered in the hospital on bioterrorism and the response of the health care agency. An important aspect of the program is the recognition of the signs and symptoms of bacterial and viral infections. A practice drill is held and the nurse recognizes that the clients admitted with possible anthrax will demonstrate: 1. Abdominal cramping, diarrhea, drooping eyelids, jaw clench, and difficulty swallowing 2. Flulike symptoms, gastrointestinal distress, and papular lesions 3. Fever, cough, chest pain, and hemoptysis 4. Vesicular skin lesions on the face and extremities
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Flulike symptoms, gastrointestinal distress, and papular lesions
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5. A 1-year-old child is scheduled to receive an IV line. The most appropriate type of restraint to use for this client to prevent removal of the IV line would be a(n): 1. Wrist restraint 2. Jacket restraint 3. Elbow restraint 4. Mummy restraint
answer
Mummy restraint
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6. A 79-year-old resident in a long-term care facility is known to "wander at night" and has fallen in the past. Which of the following is the most appropriate nursing intervention? 1. An abdominal restraint should be placed on the client during sleeping hours. 2. The client should be checked frequently during the night. 3. A radio should be left playing at the bedside to assist in reality orientation. 4. The client should be placed in a room that is away from the activity of the nurses' station.
answer
The client should be checked frequently during the night.
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7. The workmen cause an electrical fire when installing a new piece of equipment in the intensive care unit. A client is on a ventilator in the next room. The first action the nurse should take is to: 1. Pull the fire alarm 2. Attempt to extinguish the fire 3. Call the physician to obtain orders to take the client off the ventilator 4. Use an Ambu-bag and remove the client from the area
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Use an Ambu-bag and remove the client from the area
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8. In a nursing home an elderly client drops his burning cigarette in a trash can and starts a fire. The most appropriate type of fire extinguisher for the nurse to use is the: 1. Type A 2. Type B 3. Type C 4. Type D
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Type A
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9. A visiting nurse completes an assessment of the ambulatory client in the home and determines the nursing diagnosis of risk for injury related to decreased vision. Based on this assessment, the client will benefit the most from: 1. Installing fluorescent lighting throughout the house 2. Becoming oriented to the position of the furniture and stairways 3. Maintaining complete bed rest in a hospital bed with side rails 4. Applying physical restraints
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Becoming oriented to the position of the furniture and stairways
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10. Which one of the following statements by the parent of a child indicates that further teaching by the nurse is required? 1. "Now that my child is 2 years old, I can let her sit in the front seat of the car with me." 2. "I make sure that my child wears a helmet when he rides his bicycle." 3. "I have spoken to my child about safe sex practices." 4. "My child is taking swimming classes at the community center."
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"Now that my child is 2 years old, I can let her sit in the front seat of the car with me."
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11. The nurse assesses that the client may need a restraint and recognizes that: 1. An order for a restraint may be implemented indefinitely until it is no longer required by the client 2. Restraints may be ordered on an as-needed basis 3. No order or consent is necessary for restraints in long-term care facilities 4. Restraints are to be periodically removed to have the client reevaluated
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Restraints are to be periodically removed to have the client reevaluated
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12. On entering the client's room, the nurse sees a fire burning in the trash can next to the bed. The nurse removes the client and calls in the fire. The next action of the nurse is to: 1. Extinguish the fire 2. Remove all of the other clients from the unit 3. Close all the doors of client rooms 4. Move the trash can into the bathroom
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Close all the doors of client rooms
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13. A mother of a young child enters the kitchen and finds the child on the floor. There is a bottle of cleanser next to the child and particles of the substance around the child's mouth. The parent's first action should be to: 1. Call the Poison Control unit 2. Provide ipecac syrup 3. Check the child's airway and breathing 4. Remove the particles of cleanser from the mouth
answer
Check the child's airway and breathing
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14. Which of the following nursing assessment data are most reflective of hypothermia? 1. Cyanotic lips, fingers, and toes 2. Rectal temperature of 35° C (95° F) 3. Bradycardia of 56 beats per minute 4. Exposure to outdoor temperatures of <32° F
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Rectal temperature of 35° C (95° F)
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15. Which of the following clients who is experiencing the heat of mid-August is at greatest risk for heatstroke or heat exhaustion? 1. A 65-year-old diagnosed with COPD 2. A 35-year-old novice marathon runner 3. A 15-year-old playing in an outdoor tennis tournament 4. A 9-month-old whose bedroom is cooled with a mechanical fan
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A 65-year-old diagnosed with COPD
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16. The nurse should recognize which of the following clients as being at greatest risk for an unintentional death? 1. A 58-year-old who skis regularly 2. A 44-year-old alcoholic who lives alone 3. A 72-year-old identified as at high risk for falls 4. A 34-year-old diagnosed with chronic depression
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A 72-year-old identified as at high risk for falls
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17. Which of the following nursing interventions has the greatest likelihood of minimizing the risk of injury for a client who frequently gets out of bed at night to go into the bathroom? 1. Limiting fluid intake after 6 PM 2. Illuminating the pathway to the bathroom 3. Toileting the client whenever awake at night 4. Checking on the client at least hourly during the night
answer
Illuminating the pathway to the bathroom
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18. When discussing the prevention of fire-related injuries and deaths, the nurse should place the greatest emphasis on the: 1. Prevention role smoke detectors play 2. Dangers of careless smoking habits 3. Supervision of children around open flames 4. Importance of readily accessible fire extinguishers
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Dangers of careless smoking habits
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19. The nurse recognizes that the leading cause of death for the otherwise healthy 1 year old is: 1. Physical abuse 2. Accidental injury 3. Contagious diseases 4. Stranger abduction
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Accidental injury
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20. The nurse is preparing a safety-related program for a group of parents of 5 to 14 year olds. Which of the following topics is most likely to positively impact the leading cause of injury for this age-group? 1. "Keeping them safe while they play sports" 2. "Bicycle riding with safety in mind" 3. "Safety first when around water" 4. "Don't let fire hurt your child"
answer
"Bicycle riding with safety in mind"
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21. The nurse recognizes which of the following clients is at greatest risk for an accidental death? 1. A 60-year-old who is a weekend "alcoholic" 2. A 40-year-old who is a professional mountain climber 3. A 35-year-old who commutes 35 miles to work each morning 4. A 50-year-old who recently lost his job because of a work-related injury
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A 50-year-old who recently lost his job because of a work-related injury
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22. A client who is experiencing a generalized clonic-tonic seizure is at greatest risk for injury caused by: 1. The physical collapse that occurs at the onset of the seizure 2. Muscle strains that result from the severe muscle jerking during the seizure 3. The tongue laceration that occurs from jaw clenching during the seizure 4. Aspiration resulting from the temporary loss of consciousness after the seizure
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The physical collapse that occurs at the onset of the seizure
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23. Which of the following clients is at greatest risk for injury related to medical diagnoses and conditions? 1. A history of asthma and alcohol abuse 2. A history of heart failure and urinary urgency 3. A history of hypertension and wearing corrective lenses 4. A history of chronic bronchitis and impaired hearing
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A history of heart failure and urinary urgency
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24. The nurse is conducting an admission interview and assessment on a cognitively impaired, uncooperative client for the risk for injury. Which of the following options will most likely provide the information to confirm the diagnosis? 1. Base the degree of risk on observable data at the time of the client's current hospital admission. 2. Closely monitor the client's behavior and habits until risk for injury can be reasonably determined. 3. Make certain critically sound assumptions are based on the client's developmental stage and current cognitive stasis. 4. Interview the client's family, friends, and/or caregivers regarding prehospitalization risk factors.
answer
Interview the client's family, friends, and/or caregivers regarding prehospitalization risk factors.
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25. A nurse working in an acute care facility's emergency department should recognize which of the following client reports as being most suspicious of a terrorist attack? 1. Four deaths resulting from a privately owned airplane crashing into a four-story building 2. Numerous reports of respiratory distress among older adults who attended an outdoor musical event 3. 15 cases of nausea and vomiting reported over a 2-day period when 4 cases would be within normal for the facility 4. 10 children, all who attended a child-oriented arts and crafts fair, presenting with rashes on their hands and faces
answer
15 cases of nausea and vomiting reported over a 2-day period when 4 cases would be within normal for the facility
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26. The nurse is discussing safety issues with the mother of three children. Which of the following statements has the greatest possibility for decreasing the potential for injury among the children? 1. "Where do you see a need for safety improvements in your home?" 2. "Keep all toxic liquids capped and stored out of reach of the children." 3. "Installing safety gates at the top and bottom of each set of stairs will help minimize falls." 4. "Take great care to keep the children away from kitchen appliances and tools that can hurt them."
answer
Where do you see a need for safety improvements in your home?"
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27. The nurse recognizes that the greatest benefit of engaging the mother of two small children into a discussion about child-proofing her home is that: 1. The home will be safe for the immediate time being 2. If an accident occurs, it will likely be minor in nature 3. She is likely to monitor the house for safety issues in the future 4. She will serve as a role model regarding safety issues for her children
answer
She is likely to monitor the house for safety issues in the future
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28. The nurse and a mother of two small children are discussing child safety issues. Which of the following nursing interventions has the greatest potential for using collaboration to help ensure the children's safety? 1. Arranging to teach the children how to react in the case of a fire in the home 2. Teaching the children to telephone 911 if there is ever an emergency in the home 3. Helping the mother identify an emergency person for the children to telephone in the case of an emergency 4. Helping the mother create a list of emergency telephone numbers to be posted next to the home's telephone
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Helping the mother create a list of emergency telephone numbers to be posted next to the home's telephone
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29. When preparing a safety workshop for early teens (13 to 15 years old), the nurse recognizes that which of the following active strategy topics has the greatest potential for decreasing injuries in this population by affecting lifestyle changes? 1. Avoiding the nicotine habit 2. Keeping immunizations up to date 3. Eating a well-balanced, low-fat diet 4. Wearing a seat belt when riding in an automobile
answer
Wearing a seat belt when riding in an automobile
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30. The nurse is discussing measures to minimize the risk of injury from an automobile accident with an 83-year-old adult client who lives alone and claims to drive only to church, the doctor's office, and for groceries. Which of the following suggestions has the greatest potential for affecting this client's safety? 1. Take public transportation whenever it is available. 2. Plan errands around church or doctor's appointments. 3. Plan driving for short trips and only during the daylight hours. 4. Arrange for family or friends to drive you whenever it is possible.
answer
Plan driving for short trips and only during the daylight hours.
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31. Which of the following assessment findings is most critical in a client who is currently being restrained with mechanical wrist restraints? 1. Angry, loud crying 2. Urinary incontinence 3. Reddened areas on wrists 4. Hands are cool to the touch
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Hands are cool to the touch
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32. The nurse is discussing a newly ordered diuretic with an older adult client who is home-bound. Which of the following suggestions has the greatest potential for minimizing the client's risk for injury related to urinary urgency or incontinence? 1. Consider decreasing fluid intake after 6 PM. 2. Illuminate the path to the bathroom at night. 3. Encourage the client to urinate immediately before bed. 4. Encourage the client to take the medication early in the morning.
answer
Encourage the client to take the medication early in the morning.
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33. A nurse caring for an elderly client who has had surgery and is in the hospital knows that the client is at high risk for developing a nosocomial infection. One of the most important things that the nurse can do to prevent this client from obtaining a nosocomial infection is to: 1. Practice appropriate hand hygiene 2. Request prophylactic antibiotics for the client 3. Place the client in isolation 4. Encourage the client to turn, cough and deep breath every 2 hours
answer
Request prophylactic antibiotics for the client
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34. The nurse caring for an elderly client in the hospital notes on assessment that the client has a scald burn on her foot. On questioning the client, the nurse learns that the client scalded her foot when adding hot water from the tap to her bath while she was in the tub. The nurse should do which of the following? 1. Report the incident as suspected elder abuse. 2. Suggest that the temperature of the hot water heater be lowered. 3. Instruct the client that she should not be taking tub baths to prevent this from happening again. 4. Discuss the incident with social services so that arrangements can be made for the client to go to a nursing home on discharge from the hospital.
answer
Suggest that the temperature of the hot water heater be lowered.
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35. A nurse in the emergency department (ED) of a community hospital notes that an unusually high number of clients have presented in the ED with flulike symptoms, abdominal pain, nausea, vomiting, bloody diarrhea, hematemesis and itching of the hands, forearms, and head. The nurse is concerned with bioterrorism, reports this to the supervisor, and suspects an outbreak of: 1. Botulism 2. Anthrax 3. Plague 4. Smallpox
answer
Anthrax
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36. When discussing the new mother's pending discharge from the hospital, the nurse determines that additional client teaching needs to take place because of which of the following comments? 1. My husband has installed the new car seat in the middle of the backseat of our car. 2. I can't wait to put my baby in her new crib with the ensemble that my mom made- sheets, blankets, and bumper to match. 3. I need to place my baby on her back to sleep, right? 4. I have checked all my baby's toys to make sure that they don't contain lead paint.
answer
I can't wait to put my baby in her new crib with the ensemble that my mom made- sheets, blankets, and bumper to match.
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37. A confused client on a ventilator was restrained to prevent him from pulling out his endotracheal tube. Which of the following could be a possible alternative measure that the nurse could use to avoid the use of the restraints? 1. Orient the client to the environment and explain the need for the endotracheal tube. 2. Provide a trained sitter to continuously supervise the client. 3. Camouflage the endotracheal tube with stockinette dressing. 4. Promote relaxation techniques.
answer
Provide a trained sitter to continuously supervise the client.
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38. A confused client needs to have restraints to prevent him from pulling out his Foley catheter. Which of the following can the nurse delegate to the nursing assistive personnel? 1. Applying restraints 2. Obtaining a physician's order to restrain the client 3. Document the events that led to restraining the client 4. Evaluating the effectiveness of the restraints
answer
Applying restraints
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39. A nurse finds that an electrical cord has shorted out in a client's room, causing a fire. The nurse should do which of the following actions first? 1. Activate the alarm. 2. Confine the fire by closing the client's door. 3. Remove the client from the room. 4. Extinguish the fire.
answer
Remove the client from the room.
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40. Which of the following statements indicates that the client is at risk for an electrical shock at home? 1. "I had to cut off the third prong on the electrical plug so that it would fit in the extension cord." 2. "My bread got stuck in my toaster this morning, and I unplugged it before trying to remove it." 3. "I always read the owner's manual when I purchase a new electrical appliance." 4. "I always make sure that I am standing in a dry area before operating electrical equipment."
answer
My bread got stuck in my toaster this morning, and I unplugged it before trying to remove it."
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41. The nurse is caring for a client with a history of epileptic seizures. The nursing assistive personnel notifies the nurse that the client is having a seizure. The first thing that the nurse should do when arriving in the room is to: 1. Raise the bed side rails 2. Put the bed in the lowest position 3. Position the client safely 4. Provide privacy
answer
Position the client safely
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42. A client with a history of epilepsy arrives in the emergency department experiencing status epilepticus. The nurse should never do which of the following? 1. Document sequence of events, including any adverse outcomes. 2. Prepare to initiate IV access. 3. Access oxygen and suctioning equipment. 4. Open client's mouth by placing fingers on jaw and inserting thumb on bottom teeth to place oral airway between seizures.
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Open client's mouth by placing fingers on jaw and inserting thumb on bottom teeth to place oral airway between seizures.
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1. The nurse caring for clients in an acute care facility recognizes that attending to the safety of each client is most likely to result in: (Select all that apply.) 1. Freedom from illness 2. A shorter hospital stay 3. Attention to the basic human needs 4. A well-founded sense of well-being 5. Preservation of the optimal functioning level 6. Minimal exposure to bacterial cross-contamination
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2. A shorter hospital stay 3. Attention to the basic human needs 4. A well-founded sense of well-being 5. Preservation of the optimal functioning level 6. Minimal exposure to bacterial cross-contamination
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2. The nurse recognizes that children living in older housing that may contain lead-based paints may exhibit which of the following signs and symptoms? (Select all that apply.) 1. Vomiting 2. Anorexia 3. Headaches 4. Bloody urine 5. Thoracic rash 6. Swollen joints
answer
1. Vomiting 2. Anorexia 3. Headaches
