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Question 1 of 5

Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?

Correct Answer: C, E, F

Rationale: Joint Commission protocols include marking the site with a facility-designated mark (
C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (
A) is not standard. Patient representative verification (
B) and advance directives (
D) are not part of site verification.

Question 2 of 5

The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?

Correct Answer: D

Rationale: The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. Restraining the child's movements could cause constrictive injury. Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. The nurse should provide safety for the child by moving objects and protecting the head.

Question 3 of 5

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?

Correct Answer: B

Rationale: Hypotension (BP 90/50), tachycardia (pulse 132), and tachypnea (respirations 30) indicate potential shock or hemorrhage post-surgery, requiring immediate physician notification. Monitoring is secondary, and delegating or asking about feelings delays intervention.

Question 4 of 5

A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?

Correct Answer: C

Rationale: Sternal and subcostal retractions are the earliest sign of respiratory distress in newborns, indicating increased ventilatory effort.

Question 5 of 5

A client with preeclampsia is admitted with an order for magnesium sulfate. Which action by the nurse indicates an understanding of magnesium toxicity?

Correct Answer: B

Rationale: Magnesium sulfate toxicity can cause respiratory depression or arrest. Placing an airway at the bedside prepares for potential emergency intervention. The other actions are less specific to managing magnesium toxicity.

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A hyperactive client is experiencing flight of ideas. The most therapeutic activity for him would be:
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