Extract:

Question 1 of 5

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer: A,B,C,D

Rationale: Sequence of Actions: A: Evacuate clients from the area. This is the first and most crucial step to ensure the safety of all individuals in the vicinity of the fire. B: Pull the lever on the fire alarm box. Once the immediate area is clear of individuals, the next step is to alert the rest of the building by activating the fire alarm system. C: Close the fire doors on the unit. This action helps to contain the fire and prevent smoke from spreading to other areas, which can be vital in slowing the fire’s progress and safeguarding other parts of the building. D: Use a fire extinguisher to put out the fire. If the fire is small and contained, and the nurse is trained in its use, a fire extinguisher can be used to douse the flames, preventing further damage.

Question 2 of 5

A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the client’s intake for the last 8 hr? (Round your answer to the nearest whole number.)

Correct Answer: 1820 mL

Rationale: 1. IV fluids: 150 mL/hr * 8 hr = 1200 mL. 2. Juice: 4 oz * 30 mL/oz = 120 mL. 3. Water: 0.5 L * 1000 mL/L = 500 mL.
Total intake: 1200 mL + 120 mL + 500 mL = 1820 mL.

Question 3 of 5

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit. (Select all that apply.)

A. Full bounding pulseB. Cool extremitiesC. Moist crackles in the lungsD. Orthostatic hypotensionE. Flat neck veins

Correct Answer: B, D, E

Rationale: A: A full bounding pulse is a sign of increased fluid volume or fluid overload, not fluid volume deficit. B: Cool extremities can be an indication of decreased peripheral perfusion, which may occur in fluid volume deficit. C: Moist crackles in the lungs are an indication of fluid volume excess or pulmonary congestion, not fluid volume deficit. D: Orthostatic hypotension, which is a drop in blood pressure when changing from lying to standing, can be a sign of fluid volume deficit due to inadequate blood volume. E: Flat neck veins are an indication of decreased venous return and can occur in fluid volume deficit.

Question 4 of 5

A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider?

A. Heart rate 62/minB. Urine output of 200 mL per 8 hrC. Pulse oximetry 95% on room airD. BP 112/76 mm Hg

Correct Answer: B

Rationale: Heart rate 62/min: A heart rate of 62 beats per minute is within the normal range for many adults and may not require immediate reporting unless it is a significant change from the client’s baseline. Urine output of 200 mL per 8 hr: Correct. A urine output of 200 mL in 8 hours is considered low and may indicate inadequate kidney perfusion or function. It should be reported to the provider as it could be a sign of renal impairment or dehydration. Pulse oximetry 95% on room air: A pulse oximetry reading of 95% on room air is within the normal range for oxygen saturation in most healthy individuals. It does not require immediate reporting unless the client has a specific condition or baseline that warrants concern. BP 112/76 mm Hg: Blood pressure of 112/76 mm Hg is within the normal range for many adults and may not require immediate reporting unless there are specific concerns related to the client’s medical history or condition.

Question 5 of 5

A nurse is taking notes of client information on a piece of paper while receiving a report. Which of the following actions should the nurse take to dispose of the paper?

A. Obscure the client’s name with a marker prior to disposal.B. Place the paper in a trash can at the nurses’ station.C. Shred the paper in a secure container.D. Secure the paper in the nurse’s personal locker.

Correct Answer: C

Rationale: Obscure the client’s name with a marker prior to disposal: While obscuring the client’s name is better than not doing anything, it does not fully protect their confidential information. The paper could still be read by someone with access to it. Place the paper in a trash can at the nurses’ station: This action does not ensure the proper disposal of confidential information. It could be accessible to unauthorized individuals and breach the client’s privacy. Shred the paper in a secure container: Correct. Shredding confidential information is the best way to ensure that it cannot be accessed or read by unauthorized individuals. Secure the paper in the nurse’s personal locker: While securing the paper in a personal locker is better than leaving it exposed, it is not the most secure method of disposal for confidential information.