A nurse manager assesses safety on the medical-surgical floor. For each scenario, click to specify whether each scenario is safe or unsafe.
A nurse cleans their stethoscope before auscultating the client's lungs.
A nurse administers medication to a client despite the name on the ID band not matching what the client said.
A client's family lowers all of the side rails on the bed of a client who is on fall precautions.
A nurse raises the bed to waist level when completing a physical assessment.
An unlicensed assistive personnel (UAP) helps a client with a steady gait use a cane to ambulate down the hall
The nurse covers their mouth and nose with their upper arm and elbow during a sneeze.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Safe:
• A nurse cleans their stethoscope before auscultating the client's lungs
• A nurse raises the bed to waist level when completing a physical assessment
• An unlicensed assistive personnel (UAP) helps a client with a steady gait use a cane to ambulate down the hall
• The nurse covers their mouth and nose with their upper arm and elbow during a sneeze
Unsafe:
• A nurse administers medication to a client despite the name on the ID band not matching what the client said
• A client's family lowers all of the side rails on the bed of a client who is on fall precautions
Rationale
• A nurse cleans their stethoscope before auscultating the client's lungs: Cleaning the stethoscope reduces the risk of transmitting pathogens between clients, promoting infection control. This is a standard safe practice in clinical care.
• A nurse raises the bed to waist level when completing a physical assessment: Raising the bed to waist level allows the nurse to maintain proper body mechanics and reduce risk of musculoskeletal injury. This is consistent with safe patient handling protocols.
• An unlicensed assistive personnel (UAP) helps a client with a steady gait use a cane to ambulate down the hall: Assisting a client who is stable and using a mobility aid is safe, as long as the UAP follows proper techniques and ensures the client’s stability during ambulation.
• The nurse covers their mouth and nose with their upper arm and elbow during a sneeze: Using the elbow or upper arm to cover a sneeze prevents the spread of respiratory droplets, reducing infection risk. This is recommended over using hands, which can contaminate surfaces.
• A nurse administers medication to a client despite the name on the ID band not matching what the client said: Administering medication without verifying the correct identity violates the “right patient” safety protocol. This can result in medication errors and harm, making it unsafe.
• A client's family lowers all of the side rails on the bed of a client who is on fall precautions: Lowering side rails for a patient at fall risk increases the likelihood of injury from falls. Side rails should be maintained according to the patient’s safety plan, making this action unsafe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Treat all clients the same no matter their background, culture, needs, or diagnoses: Treating all clients the same ignores individual needs, cultural differences, and social determinants of health. Effective care requires recognizing and addressing each client’s unique context.
B. Rely on colleagues to identify any personal biases in clinical decision-making: While peer feedback can be helpful, relying solely on others does not promote self-awareness or personal growth. The nurse must actively engage in self-reflection to identify and manage biases.
C. Refuse to treat clients of different backgrounds to avoid misunderstandings: Avoiding clients based on cultural differences is unethical, discriminatory, and contrary to professional nursing standards. It denies clients access to equitable care.
D. Keep a journal to document experiences and feelings about client interactions: Reflective journaling allows the nurse to recognize patterns, triggers, and personal biases that may affect care. This practice promotes self-awareness, critical reflection, and development of culturally competent nursing interventions.
Correct Answer is A
Explanation
A. Mood: Behavioral assessment during the general survey involves observing the client’s affect, emotional state, and overall behavior. Evaluating mood helps the nurse understand how the client is coping, their level of emotional stability, and any signs of anxiety, depression, or distress. It provides insight into psychological and emotional well-being, which is essential for holistic care planning.
B. Age: Age is a component of the general survey that falls under physical characteristics rather than behavior. It helps establish baseline expectations for growth, development, and age-appropriate functioning, but it does not provide information about the client’s emotional state or behavior.
C. Posture: Posture is part of the physical appearance assessment within the general survey. It provides information about musculoskeletal health, possible pain, or functional limitations but does not reflect the client’s behavioral or emotional status.
D. Gait: Gait assessment evaluates how a client moves, including balance, coordination, and mobility. While it offers important physical and neurological information, it does not give direct insight into the client’s mood, affect, or behavioral patterns.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.