Extract:

Question 1 of 5

A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include?

A. Alarm clock that shakes the bedB. Flashing smoke alarmC. Low-pitched buzzer doorbellD. Telephone with an amplified receiver

Correct Answer: B

Rationale: Alarm clock that shakes the bed: While a vibrating alarm clock can be helpful for waking a person with hearing loss, it may not be a priority modification for safety in the home environment. Flashing smoke alarm: Correct. A flashing smoke alarm is a priority modification because it addresses the safety concern of alerting the client in the event of a fire or smoke in the home. The flashing light serves as an effective visual cue to notify the client about the danger. Low-pitched buzzer doorbell: A low-pitched buzzer doorbell can be beneficial for individuals with hearing loss, but it is not as critical as having a flashing smoke alarm for immediate safety. Telephone with an amplified receiver: An amplified telephone receiver can improve communication for clients with hearing loss but is not as essential for immediate safety as a flashing smoke alarm.

Question 2 of 5

A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect?

A. The client’s body should be placed on the floor.B. The client’s oldest child will bathe the body.C. The client’s face should be turned toward Mecca.D. The client’s body will be adorned with amulets.

Correct Answer: C

Rationale: The client’s body should be placed on the floor: This is not a specific cultural practice in Islam. In Islamic tradition, the deceased person is usually placed on a raised surface, like a table or bed, to allow family and friends to gather around for prayers and final respects. The client’s oldest child will bathe the body: This is not a specific cultural practice in Islam. In Islamic tradition, the body is usually washed by individuals of the same gender who are experienced in the ritual washing of the deceased, known as 'Ghusl.' The client’s face should be turned toward Mecca: Correct. In Islamic tradition, when a person dies, it is customary to position the body with the head facing the Kaaba in Mecca, which is the holy city in Islam and the direction toward which Muslims pray. The client’s body will be adorned with amulets: This is not a specific cultural practice in Islam. While some individuals in various cultures may use amulets or charms for protection, it is not a universal Islamic practice for the deceased.

Question 3 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 4 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 5 of 5

A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take?

A. Provide privacy for the clientB. Expose hair of the body as a

Correct Answer: A

Rationale: Provide privacy for the client: CORRECT. The nurse should promote a therapeutic environment by providing privacy while data is being collected for a health assessment. Expose hair of the body as an: INCORRECT.
To promote a therapeutic environment, the nurse should expose only the area of the body from which data is being collected.