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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["D","E","G"]

Explanation

A. Rhinitis of right nare present: This is an observable sign noted by the nurse during assessment, making it objective data.

B. Pulse 110 bpm: Measured using a monitor or palpation, pulse is a quantifiable, objective finding.

C. Temperature 101.8 F (38.7 C): Body temperature is measured with a thermometer, making it objective data.

D. Reports tenderness during palpation of sinus cavities: Tenderness is a sensation reported by the client, reflecting their personal experience, so it is subjective data.

E. Reports light sensitivity: Light sensitivity is reported by the client and cannot be directly measured, making it subjective.

F. Lymphadenopathy >2 cm: Enlarged lymph nodes are assessed and measured by the nurse, making this objective data.

G. History of allergies to pollen, dust, animal dander: The client provides this information, making it subjective data derived from their personal history.

H. Right eye periorbital edema present: Swelling around the eye is observable, measured, and documented by the nurse, so it is objective data.

A. A client with a burn on their forearm sustained from boiling water B. A client with a right ankle fracture unable to place any weight on it C. A client with severe abdominal pain who is pale and diaphoretic D. A client with a head laceration being controlled with pressure

Correct Answer is C

Explanation

A. A client with a burn on their forearm sustained from boiling water: While burns require assessment and care, a forearm burn without signs of systemic compromise is not immediately life-threatening and can wait after more urgent cases.

B. A client with a right ankle fracture unable to place any weight on it: An isolated fracture causes pain and limited mobility but is not life-threatening, making it lower priority in triage compared to clients with potential systemic compromise.

C. A client with severe abdominal pain who is pale and diaphoretic: Pallor and diaphoresis indicate possible shock or serious internal pathology. This client is at highest risk for rapid deterioration and requires immediate assessment and intervention.

D. A client with a head laceration being controlled with pressure: If bleeding is controlled and the client is stable, this is urgent but not immediately life-threatening, so the client can be assessed after those showing signs of shock or systemic compromise.

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A nurse manager assesses safety on the medical-surgical floor. For each scenario, click to specify whether each scenario is safe or unsafe.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Review the electronic health record. Which finding(s) should the nurse identify as subjective data? Select all that apply.

Correct Answer is ["D","E","G"]

Explanation

The nurse is triaging a group of clients in the emergency department. Which client should be assessed first?

Correct Answer is C

Explanation

A nurse is performing the behavioral assessment of the general survey. Which assessment should the nurse include related to behavior?

While providing the client with morning medications, the client reports new abdominal pain. What assessment question should the nurse ask next?

During a client interview, which is an example of an active listening technique a nurse can use to improve communication?

A nurse is taking care of a client with a cultural background different from the nurse. Which step should the nurse take first to provide culturally competent care?

A nurse educates a client with limited English-speaking skills about their disease. What action should the nurse take to ensure the client is able to understand the teaching?

A client requests to hang an amulet above their bed for protection while in the hospital. The nurse believes that the only thing that will help the client is medical treatment. Which action should the nurse take?

A nurse is conducting an assessment of the client. Which question should the nurse ask the client to assess their mood?

The nurse is caring for a client who is of a different culture than that of the nurse. When the nurse begins the physical assessment, the client seems apprehensive. What action should the nurse take?