NURSING 2362 Module 6 Exam with rationale

NURSING 2362 Module 6 Exam

Questions

1.ID: 8482541809Which event would require a nurse to complete and file an

incident report?

A A client has a seizure.

B The nurse determines that a client would benefit from the use of a walker to

ambulate.

C The nurse, preparing an intravenous infusion, notes that the battery of an

intravenous infusion pump is not working.

D 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 possible points. 

2.ID: 8482539805A 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?

A Notifying the nursing supervisor

B Tearing up and discarding the incident report

C Telling the physician that the error warrants the completion of an incident report

Correct

D 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 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 possible points.

3.ID: 8482539895Contact precautions are initiated for a client with

methicillinresistant Staphylococcus aureus (MRSA) infection. The nurse, providing

instructions to a nursing assistant about caring for the client, tells the assistant:

A To transfer the client to a semiprivate room

B That gloves only are needed to care for the client

C To wear gloves and a gown when changing the client's bed linen. Correct

D To wear a gown when caring for the client and remove the gown immediately

after leaving the client’s room

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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.