Hesi:Saunder Online review Module 6

dent report? A client has a seizure. The nurse determines that a client would benefit from the use of a walker to ambulate. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor’s blood pressure and takes the visitor to the emergency department for treatment. Correct Rationale: An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. Examples of incidents include client falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An incident report does not need to be filed if a client has a seizure unless the client sustains injury as a result of the seizure. If the nurse determines that a client would benefit from the use of a walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes that the battery of an intravenous infusion pump is not working, he or she should obtain a functioning pump and send the nonfunctioning pump to the appropriate department for repair. Test-Taking Strategy: Use the process of elimination and read each option carefully. Recalling that an incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client will direct you to the correct option. Review the reasons for filing an incident report if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 336, 337, 403). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Clinical Judgment, Health Policy HESI Concepts: Clinical Decision-Making/Clinical Judgment, Health Policy/Systems Awarded 1.0 points out of 1.0 possibleA B C D points. 2. ID: 9476944425 A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol (Tenormin) was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client’s vital signs, completes an incident report, and calls the physician to report the error. The physician tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? Notifying the nursing supervisor Tearing up and discarding the incident report Telling the physician that the error warrants the completion of an incident report Correct Telling the nursing supervisor that the physician did not want an incident report completed and filed Rationale: Incident reports are an important part of a healthcare agency’s quality improvement program. An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. An example of an incident is administering a medication at a time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is completed and filed in accordance with agency guidelines. The nursing supervisor would be notified of the incident; however, on the basis of the data in the question, the nurse should tell the physician that the error warrants completion and follow-through with an incident report. Therefore, the other options are incorrect. Test-Taking Strategy: Focus on the subject of the question, the physician’s telling the nurse that an incident report is not needed. Eliminate the options that are comparable or alike in that they involve notifying the nursing supervisor. To select from the remaining options, recall the purpose of an incident report to select the correct option. Review the procedures involved in completing and filing incident reports if you had difficulty with this question. Reference: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 557, 558). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care EnvironmentA B C D Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Clinical Judgment, Health Policy HESI Concepts: Clinical Decision-Making/Clinical Judgment, Health Policy/Systems Awarded 1.0 points out of 1.0 possible points. 3. ID: 9476948372 Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant: To transfer the client to a semiprivate room That gloves only are needed to care for the client To wear gloves and a gown when changing the client's bed linen. Correct To wear a gown when caring for the client and remove the gown immediately after leaving the client’s room Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client contact is anticipated. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood or body fluids, secretions, or excretions. The client should be placed in a private room or, if a private room is not available, in a semiprivate room with another client who has active infection with the same microorganism but no other infection. The nursing assistant would remove the protective gear before leaving the client’s room. Test-Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed-ended word “only.” Next eliminate the option that involves removal of the gown after leaving the client’s room. To select from the remaining options, read each carefully and visualize the procedure instituted for contact precautions, which will direct you to the correct option. If you had difficulty with this question, review contact precautions. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 655, 663). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Giddens Concepts: Infection, LeadershipA B C D HESI Concepts: Collaboration/Managing Care—Leadership, Infection Awarded 1.0 points out of 1.0 possible points. 4. ID: 10466367548 A nurse hears someone calling, “Help! My bed is on fire!” On entering the room, the nurse finds a client trying to beat out the flames with a pillow. Place in order of priority the actions that the nurse should take: Correct Removing the client from the room Pulling the nearest fire alarm Closing the door to the room Running to get the nearest fire extinguisher Rationale: A nurse who encounters a fire emergency should think of the mnemonic RACE. The first step is to remove the client from the room, after which the nurse should activate the fire alarm, contain the fire, and extinguish the fire. This is a universal standard that may be applied to any type of fire emergency. Removing the client from the room is the first step. Pulling the nearest fire alarm is the second step (alarm). Closing the door to the room to contain the fire is the third action. Obtaining the nearest fire extinguisher to put out the fire is the fourth action. Test-Taking Strategy: Focus on the subject, the steps to take in a fire emergency. With this in mind, sequence the actions, using the RACE mnemonic. Review fire safety if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 839, 840). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 5. ID: 9476945972 The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse shouldA B C D instruct the mother to immediately: Call a poison control center Correct Administer an excessive amount of fluids to induce vomiting Call an ambulance to bring the child to the e