A nurse is admitting a new client. Which of the following actions should the
nurse take while performing medication reconciliation?
A.Verify the client's name on their identification bracelet with the
medication administration record.
B.Call the pharmacy to determine whether the client's medications are
available.
C.Compare the client's home medications with the provider's prescriptions.
D.Place the client's home medication bottles in a secure location. - ANS
✓C.Compare the client's home medications with the provider's prescriptions.
A nurse is providing discharge instructions to a client who will be using a
walker. Which of the following client statements indicates an
understanding of the teaching?
A. "I can place an extension cord across my living room to plug in my
television."
B. "I will hire someone to trim the tree that hangs low over the stairs of my
front porch."
C. "I will place my alarm clock on my bedroom dresser across the room."
D. "I will replace the old throw rug in the kitchen with a new one." - ANS ✓B.
"I will hire someone to trim the tree that hangs low over the stairs of my front
porch."
BSN 225
, 2
BSN
When describing safety issues and related mortality to a local senior
citizens group, what would the nurse identify as the leading cause of
hospital admission for trauma in older adults?
A.Fires
B.Exposure to temperature extremes
C.Intimate partner violence
D.Falls - ANS ✓D. Falls
When completing a safety event report, the nurse should:
A.Include suggestions on how to prevent the incident from recurring.
B.Provide minimal information about the incident
C.Discuss the details with the patient before documenting them.
D.Objectively describe the incident in detail - ANS ✓D. Objectively describe
the incident in detail
The nurse obtains a prescription from a health care provider to restrain a
client and instructs an unlicensed assistive personnel (UAP) to apply the
safety device to the client. Which observation of unsafe application of the
safety device would indicate that further instruction is required by the
UAP?
A.Placing a safety knot in the safety device straps
B.Safely securing the safety device straps to the side rails
C.Applying safety device straps that do not tighten when force is applied
against them
D.Securing so that 2 fingers can slide easily between the safety device and
the client's skin - ANS ✓B.Safely securing the safety device straps to the side
rails
BSN 225
, 3
BSN
Rationale: Safety device straps are secured to the bed frame and never to
the side rails to avoid injury if the side rails are released.
The nurse cares for the client who is confused. The health care provider
ordered that the client have cotton wrist restraints to prevent the client
from attempting to remove the intravenous (IV) and indwelling catheter.
Which action is essential for the nurse to include in the client's care plan?
A.Remove the restraints for 1 hour every 4 hours.
B.Remove the restraints, assess limbs, and provide skin care every hour.
C.Request that the health care provider order removal of the wrist
restraints for skin assessment.
D.Ask the client, "Are you developing any problems from the restraints?" -
ANS ✓B. Remove the restraints, assess limbs, and provide skin care every hour.
The newly hired nurse is assigned to a very disoriented client with soft
wrist restraints. The nurse asks the head nurse for the purpose of the
client's restraints. Which response by the head nurse is correct?
A. "The restraints will reduce the client's confusion."
B. "The restraints discourage the client from ambulating alone."
C. "The restraints prevent injuries from occurring to the client."
D. "The restraints prevent the client from becoming violent." - ANS ✓B. "The
restraints discourage the client from ambulating alone."
Ratoinale: Restraints should be used as the last resort in dealing with
confused, agitated, violent, or disoriented clients. In the event of preventing
a disoriented client from ambulating without assistance, a soft wrist
restraint can be used, provided that the family members were informed
and signed a consent form and that the nurse closely monitors and
documents the use of restraints. The restraint will not help in decreasing
the client's confusion. Restraints can sometimes even cause injury to the
client, such as pressure injuries, skin breakdown, abrasions, asphyxia, or
BSN 225
, 4
BSN
depression, if not monitored appropriately. A violent client must be calmed
down first before considering any use of restraints right away.
Restraints can be used for all of the following purposes except to:
A. Prevent a confused client from removing tubes, such as IV lines,
catheters, and feeding tubes
B. Prevent a client from falling out of the bed
C. Discourage a client from ambulating alone when he requires assistance
for his safety
D. Prevent a client from becoming confused or disoriented - ANS ✓D.
Prevent a client from becoming confused or disoriented
Rationale: By restricting a patient's movements, restraints may increase
stress and lead to confusion instead of preventing it
The nurse is preparing to examine a client's abdomen. Identify the proper
order of the steps in the assessment of the abdomen, using the numbers 1-
4, with 1 = the first technique and 4 = the last technique:
Which situation would require the nurse to obtain a focused assessment?
Select all that apply.
BSN 225
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