Question 1

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?

Accepted Answer

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. D

Question 2

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

Accepted Answer

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 D

Question 3

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

Accepted Answer

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 A, C, D, E

Question 4

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

Accepted Answer

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 5

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

Accepted Answer

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

Question 6

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

Accepted Answer

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 7

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.)

Accepted Answer

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

Question 8

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

Accepted Answer

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 9

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

Accepted Answer

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 10

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

Accepted Answer

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 11

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?

Accepted Answer

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 12

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

Accepted Answer

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.

Question 13

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

Accepted Answer

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 14

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

Accepted Answer

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 15

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

Accepted Answer

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

Question 16

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?

Accepted Answer

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.

Question 17

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?

Accepted Answer

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 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?

Accepted Answer

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.)

Accepted Answer

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

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?

Accepted Answer

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

Exam 1: Foundations of Safe Client Care