Exam (elaborations)
SAUNDERS SAFETY EXAM 2 2024/2025
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SAUNDERS SAFETY EXAM 2 2024/2025
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SAUNDERS SAFETY EXAM 2 2024/2025A client has a prescription to receive 1000 mL of 5% dextrose in 0.45%
sodium chloride. After gathering the appropriate equipment, the nurse
takes which action first before spiking the IV bag with the tubing?
1.Uncaps the distal end of the tubing
2.Uncaps the spike portion of the tubing
3.Opens the roller clamp on the IV tubing
4.Closes the roller clamp on the IV tubing - Precise Answer ✔✔4.Closes
the roller clamp on the IV tubing
The nurse is assigned to care for a client with a peripheral intravenous
(IV) infusion. The nurse is providing hygiene care to the client and
should avoid which while changing the client's hospital gown?
1.Using a hospital gown with snaps at the sleeves
2.Disconnecting the IV tubing from the catheter in the vein 3.Checking
the IV flow rate immediately after changing the hospital gown
4.Putting the bag and tubing through the sleeve, followed by the client's
arm - Precise Answer ✔✔2.Disconnecting the IV tubing from the
catheter in the vein
The nurse is making a worksheet and listing the tasks that need to be
performed for assigned adult clients during the shift. The nurse writes on
,the plan to check the intravenous (IV) of an assigned client who is
receiving fluid replacement therapy how frequently?
1.Every hour
2.Every 2 hours
3.Every 3 hours
4.Every 4 hours - Precise Answer ✔✔1.Every hour
The nurse enters a client's room and finds that the wastebasket is on fire.
The nurse quickly assists the client out of the room. Which is the next
nursing action?
1.Call for help.
2.Extinguish the fire.
3.Activate the fire alarm.
4.Confine the fire by closing the room door - Precise Answer
✔✔3.Activate the fire alarm
The nurse obtains a prescription to restrain a client using a belt (safety)
restraint and instructs the unlicensed assistive personnel (UAP) to apply
the restraint. Which observation, if made by the nurse, indicates unsafe
application of the restraint?
1.A safety knot is made in the restraint strap.
2.The restraint straps are safely secured to the side rails.
3.The restraint strap does not tighten when force is applied against it.
4.The restraint is secure, and the client is able to turn from back to side. -
Precise Answer ✔✔2.The restraint straps are safely secured to the side
rails.
,The nurse applies wrist restraints, prescribed to prevent a client from
pulling out a nasogastric tube. How should the nurse determine that the
restraints are not too constrictive?
1.Observe the skin in the wrist area for redness.
2.Check the temperature of the skin in the hands.
3.Place two fingers under the restraint to determine snugness. 4.Remove
the restraint and exercise the extremity in 2 hours. - Precise Answer
✔✔3.Place two fingers under the restraint to determine snugness.
The nurse is assisting with planning care for a client with an internal
radiation implant. Which should be included in the plan of care? Select
all that apply.
1.Wearing gloves when emptying the client's bedpan
2.Keeping all linens in the room until the implant is removed 3.Wearing
a film (dosimeter) badge when in the client's room 4.Wearing a lead
apron when providing direct care to the client 5.Placing the client in a
semiprivate room at the end of the hallway - Precise Answer
✔✔1.Wearing gloves when emptying the client's bedpan 2.Keeping all
linens in the room until the implant is removed
3.Wearing a film (dosimeter) badge when in the client's room
4.Wearing a lead apron when providing direct care to the client
The nurse enters the nursing lounge and discovers that a chair is on fire.
The nurse activates the alarm, closes the lounge door, and obtains the
fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire
extinguisher. Which is the next action the nurse should perform?
, 1.Aim at the base of the fire.
2.Squeeze the handle on the extinguisher.
3.Sweep the fire from side to side with the extinguisher.
4.Sweep the fire from top to bottom with the extinguisher. - Precise
Answer ✔✔1.Aim at the base of the fire
The nurse is preparing to reposition a dependent client who weighs more
than 250 lbs. Which interventions should the nurse use to move this
client? Select all that apply.
1.Use a friction-reducing slide sheet.
2.Use a mechanical lift to move the client.
3.Place the client in Trendelenburg's position.
4.Keep elbows close and work close to the body.
5.Administer oral pain medication 5 minutes before moving the client.
6.Obtain assistance of a second caregiver to assist with mechanical aids.
- Precise Answer ✔✔1.Use a friction-reducing slide sheet.
2.Use a mechanical lift to move the client.
4.Keep elbows close and work close to the body
6.Obtain assistance of a second caregiver to assist with mechanical aids
The nurse is assigned to assist with caring for a client with esophageal
varices who had a Sengstaken-Blakemore tube inserted because other
treatment measures were unsuccessful. The nurse should check the
client's room to ensure that which priority item is at the bedside?
1.An obturator
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