Deck 1: Foundations of Safe Client Care

Question 1

What was the main finding of the Institute of Medicine's 1999 report To Err is Human: Building a Better Healthcare System?

A) Nursing personnel need better training and education to prevent errors.
B) Registered nurses should take the lead in reducing healthcare-associated errors.
C) Faulty systems, processes, and conditions combined cause the majority of errors.
D) Over 198,000 patients die each year when they are patients in a hospital.

Answer 1

Faulty systems, processes, and conditions combined cause the majority of errors.

Question 2

A nurse meets the assigned clients at the start of a shift. After performing hand hygiene and introducing one's self, what does the nurse do next?

A) Begin a head-to-toe assessment.
B) Identify the client using two identifiers.
C) Assess the client for pain.
D) Ensure the call light is within reach.

Answer 2

Identify the client using two identifiers.

Question 3

A nurse has worked with the same client for 2 days. When entering the room to administer medications, the nurse performs hand hygiene. What action does the nurse take next?

A) Provide any needed teaching.
B) Ask if the client has any care requests.
C) Assess vital signs and pain.
D) Identify the client using two identifiers.

Answer 3

Identify the client using two identifiers.

Question 4

A nurse's neighbor states "My father got a nosocomial infection after surgery!" What does the nurse understand happened to the client?

A) The client received contaminated blood products.
B) The client nearly died from a postoperative infection.
C) The client acquired an infection while in the hospital.
D) The client received poor preoperative skin preparation.

Question 5

A nurse is making rounds on clients at risk for infection. Which client does the nurse see first?

A) A client with an intravenous (IV) line
B) A client who has a central line
C) A client with an indwelling bladder catheter
D) A client with an IV and bladder catheter

Question 6

A nursing manager concerned about the infection rate on the unit wants to implement measures to reduce the transmission of infectious organisms. What action by the manager is best?

A) Provide a stethoscope dedicated to each client.
B) Ensure gloves are well-stocked in each room.
C) Restrict all plants and fresh foods from rooms.
D) Screen all visitors for contagious illnesses.

Question 7

A nurse is observing a student nurse. What action by the student demonstrates the need for more education on Standard Precautions?

A) The student performs hand hygiene before all client contacts.
B) The student conscientiously wears gloves when taking vital signs.
C) The student confirms that urine possibly contains infectious microbes.
D) The student wears a gown when cleaning liquid stool off the client.

Question 8

A faculty member has taught the correct technique for taking gloves off (doffing). While observing students practice, which action by a student indicates the need to review the material?

A) Pulls glove off dominant hand first
B) Takes first glove off by grasping it on the outside
C) Takes second glove off by grasping it under the cuff
D) Turns the gloves inside out when second glove is removed

Question 9

In order to move a client safely, which of the following actions does the nurse take first?

A) Gather enough help for the task.
B) Assess the client's ability to bear weight.
C) Delegate using the lift chair.
D) Administer pain medication.

Question 10

Hospital administration has rejected a request from nursing services for ceiling-mounted lifting/transferring devices pointing to the expense. What response by the Chief Nursing Officer would be best?

A) "We need the equipment to stay competitive in hiring nurses."
B) "They are required by The Joint Commission so we have to get them."
C) "The cost of employee injuries from lifting is more expensive."
D) "We will save money with fewer client-injury lawsuits being filed."

Question 11

The nurse places a bed-bound client in the position shown. What other considerations would the nurse have for this client?

A) Include a Trochanter roll to prevent of the neck.
B) Assess whether the client needs support to prevent foot drop.
C) Monitor for signs of increased intracranial pressure.
D) Place a rolled-up washcloth in the client's hands.

Question 12

A nurse has applied restraints to a client. After documenting the care and ensuring the client is safe, what action does the nurse take next?

A) Call the provider and request a prescription for the restraints.
B) Alert the hospital's Risk Management department.
C) Plan to check the client at a minimum of every 2 hours.
D) Assign assistive personnel to sit with the client.

Question 13

The nursing student applies restraints. What action by the student demonstrates the need for more education on this procedure?

A) The student attempts other methods to prevent harm before applying the restraints.
B) The student inserts two fingers between the restraint and client skin to check for tightness.
C) The student secures the restraint by tying the restraint to the side rail but out of client reach.
D) The student reassesses the client's need for the restraint at least every 2 hours.

Question 14

The new nurse grumbles "Why are there so many regulations on using restraints?" What response by the mentor is best?

A) "Clients have the right to be free from restraint or seclusion unless medically necessary."
B) "Following all these regulations helps prevent law suits."
C) "Accrediting bodies aren't in favor of using restraints so they make up regulations."
D) "Because restraints have been shown to actually increase injuries."

Question 15

A nurse is caring for a client in Droplet Precautions. What action does the nurse take to decrease a common complaint from clients in isolation?

A) Keeps the temperature comfortable for the client, not personnel wearing gowns and gloves
B) Stops by to see the client frequently, even if it's only by standing in the doorway
C) Calls the hospital chaplain to come visit with the client each morning
D) Asks volunteer services to bring the client books and magazines to read

Question 16

After assessing a client, the nurse cleans the stethoscope. What cleaning agent chosen by the nurse is most appropriate?

A) 70% isopropyl alcohol
B) Diluted bleach 1:10 solution
C) Cidex
D) Hydrogen peroxide

Question 17

After giving an injection, which action by the nurse is most appropriate?

A) Breaks needle off the syringe and places it in the sharps box
B) Recaps the needle and carries the syringe to the sharps box
C) Engages the syringe's safety device to cover the needle
D) Twists the needle off and throws the syringe away

Question 18

The nurse is working in a neonatal intensive care unit. When an infant's oxygen saturation drops, what action does the nurse take first?

A) Place the neonate prone.
B) Call a code blue.
C) Inform the provider.
D) Call respiratory therapy.

Question 19

The nurse learns that which of the following must be demonstrated to prove a claim of malpractice? (Select all that apply.)

A) Duty
B) Breach of duty
C) Physical injury
D) Emotional distress
E) Cause: the injury was caused by the breach of duty

Question 20

The nurse learns that which of the following are principles of body mechanics? (Select all that apply.)

A) Make a wide, stable base with your feet.
B) Put the bed at the correct height.
C) Put the work directly in front of you.
D) Keep the client as far away from you as possible.
E) Keep the bed in the same position.

Question 21

Which of the following devices are inconsistent with the nurse's knowledge of types of restraint devices? (Select all that apply.)

A) A seat belt on a stroller
B) A thumbless mitten
C) A single raised side rail
D) A device applied during a dental procedure
E) A positioning restraint in the operating room

Question 22

A nurse needs to transfer a client from a bed directly onto a stretcher. The client weighs 274 pounds (124.54 kg). Which of the following are appropriate options for the nurse gather prior to performing this transfer? (Select all that apply.)

A) 1 to 2 caregivers
B) A lateral transfer board
C) Air assisted device
D) Mechanical lateral assistive device
E) Nonskid slippers
F) Friction-reducing device

Question 23

The charge nurse is conducting an audit on compliance with Transmission-Based Precautions. Which action by the nursing staff shows good understanding and correct application of these precautions? (Select all that apply.)

A) Contact Precautions: Dons gloves and a gown before entering the room
B) Droplet Precautions: Cares for the client only if immunity to the disease is present
C) Standard Precautions: Combines Standard Precautions with any other precautions
D) Droplet Precautions: Wears a mask when taking client vital signs
E) Two levels of Precautions: Maintains compliance with both types of precautions
F) Contact Precautions: Places two patients with MRSA in the same room

Question 24

What does the nurse remember about appropriate hand hygiene? (Select all that apply.)

A) Alcohol-based hand sanitizers are the gold standard for hand hygiene.
B) Washing with soap and water is needed after using the toilet.
C) After contact with certain organisms, soap and water is required.
D) Alcohol-based hand sanitizers are only good for a few client types.
E) The presence of hand sanitizers decreases the frequency of hand hygiene.

Question 25

Which of the following are Joint Commission accepted unique client identifiers in a hospital? (Select all that apply.)

A) Name
B) Date of birth
C) Room number
D) Photograph in medical record
E) Hospital account number
F) Social security number