Question

A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency. (Move the steps into the box on the right. placing them in the selected order of performance. Use all the steps.)

Answer 1

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available

Rationale :

🔷 The correct sequence follows the RACE fire-response priority: Rescue, Alarm, Confine, Extinguish/Evacuate.

🔷 Rescuing clients removes those in immediate danger first, which prevents injury or death.

🔷 Pulling the alarm activates emergency response and alerts others to evacuate and assist.

🔷 Confining the fire (closing doors/windows) reduces oxygen flow and slows smoke and flame spread.

🔷 Extinguishing is done only if the fire is small and the nurse has a clear exit path and proper training.

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Answer 2

Correct Answers:

An older adult client who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7.32

Rationale :

💠 In a disaster, discharge priority is given to the most stable client with improving objective data.

💠 A DKA client whose ABGs show pH 7.32 is moving toward correction of acidosis and is closer to stability than those with acute surgical or pulmonary risks.

💠 DKA stabilization is monitored by pH improvement, glucose control, hydration status, and electrolyte normalization, and this ABG suggests progress.

💠 The other options include high-risk conditions that can rapidly deteriorate or require imminent interventions.

💠 Freeing beds requires selecting a client with the lowest immediate complication risk and evidence of recovery.

A middle adult who is 36 hr postoperative from an open laminectomy

💠Early post-op spine clients are at risk for bleeding, neurologic changes, and infection.

💠They typically require continued monitoring for mobility and neurovascular status.

An adolescent client who was admitted 24 hr ago due to a spontaneous pneumothorax

💠Pneumothorax can worsen suddenly with risk for respiratory compromise.

💠This client needs close monitoring for re-expansion and recurrence.

A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy

💠Pre-op clients often need bowel prep, labs, hydration, and surgical readiness checks.

💠Discharging now could delay urgent surgery planning and increase complications.

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Answer 3

Correct Answers:

“Speaking to me like that makes me uncomfortable."

Rationale :

🟣 This statement is direct, professional, and sets a clear boundary without escalating conflict.

🟣 It communicates that the behavior is unwelcome, which is essential in addressing harassment.

🟣 It focuses on the speaker’s behavior and its impact, supporting respectful workplace communication.

🟣 Boundary-setting is the first step before reporting if the behavior continues or is severe.

🟣 A calm, assertive response helps protect psychological safety and professional standards.

“You need to lower your voice. Others can hear you."

🟣This focuses on volume, not the inappropriate content, so the behavior may continue.

🟣It fails to set a boundary that the comment is unacceptable.

"Whether or not I am a good lover is irrelevant."

🟣This still engages the sexual topic and can unintentionally encourage continued remarks.

🟣It does not clearly state the behavior is unwanted.

“Let's talk about something else."

🟣This redirects but does not explicitly address the harassing behavior.

🟣Lack of clear limits can allow repeated inappropriate comments.

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Answer 4

Correct Answers:

The AP has the knowledge and skill to perform the task

Rationale :

🔶 The right person is a core delegation principle: the task must match the AP’s competency and training.

🔶 Delegation is safe only when the delegatee can perform the task correctly and within their scope.

🔶 The nurse remains accountable for outcomes, so verifying skills and knowledge protects the client.

🔶 Competency-based delegation reduces errors and improves workflow efficiency.

🔶 This is a foundational safety checkpoint before giving any assignment.

The AP's rapport with clients

🔶Rapport is helpful but does not confirm the AP can perform the task safely.

🔶Delegation requires competency, not comfort alone.

The AP's ability to complete the task without assistance

🔶Some tasks may be delegated with supervision or assistance based on policy.

🔶Independence is not the defining requirement; safe performance is.

The AP's ability to prioritize

🔶AP prioritization matters, but the nurse must still provide clear direction and expectations.

🔶The key delegation right is matching task to competent personnel.

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Answer 5

Correct Answers:

Compare the number of medication errors before and after the action was implemented.

Rationale :

🔵The most direct evaluation of a safety intervention is measuring outcomes using objective data.

🔵Comparing medication errors pre-implementation vs post-implementation shows whether the change improved patient safety.

🔵This method supports quality improvement using measurable indicators rather than opinions.

🔵Trend comparison helps determine if the intervention should be continued, revised, or expanded.

🔵It aligns with performance improvement models that focus on data-driven evaluation.

Conduct a study about the time and money costs of implementing the change.

🔵Cost analysis measures efficiency, not whether errors actually decreased.

🔵The primary goal is reduced medication errors, not cost.

Establish a benchmark to identify a standard of performance.

🔵Benchmarks set targets, but they do not directly evaluate whether the intervention worked.

🔵The question asks how to measure success of the change, which requires outcome comparison.

Provide the staff with a questionnaire to quantify staff satisfaction with the changes.

🔵Satisfaction is subjective and does not prove client safety improved.

🔵Error rates are a more valid measure of success.

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Answer 6

Correct Answers:

Check the client's medical record for the provider's prescription.

Rationale :

🟢 When a client questions a treatment, the nurse must verify that it is ordered and appropriate before proceeding.

🟢 Checking the record ensures the procedure is authorized, correctly prescribed, and not a mistaken plan.

🟢 This protects client rights and supports informed participation in care.

🟢 Verification also prevents medication/procedure errors and aligns with safe practice standards.

🟢 After confirmation, the nurse can re-educate the client and obtain cooperation appropriately.

Assure the client that enemas are commonly prescribed for constipation.

🟢Common use does not confirm it is ordered for this client.

🟢The nurse must verify the prescription first.

Explain to the client that the provider prescribed the procedure.

🟢The client’s concern signals the nurse should confirm the order rather than assume.

🟢Verification prevents errors and supports trust.

Inform the charge nurse that the client refused the enema.

🟢The client has questioned the plan, not clearly refused after education and verification.

🟢Confirm the order first, then address informed refusal if it occurs.

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Answer 7

Correct Answers:

Nonmaleficence

Rationale :

⚫ Protecting a patient’s private health information prevents harm such as stigma, discrimination, or loss of trust.

⚫ Nonmaleficence means “do no harm,” and violating confidentiality can cause real emotional and social harm.

⚫ The nurse is correctly limiting disclosure to those with a legitimate need-to-know.

⚫ Maintaining confidentiality supports professional ethics and legal expectations of privacy.

⚫ The nurse’s response demonstrates protection of the patient from avoidable harm.

Utility

⚫Utility focuses on the greatest good for the greatest number.

⚫Confidentiality here is primarily about preventing harm to an individual patient.

Justice

⚫Justice relates to fairness and equal treatment.

⚫This situation concerns privacy and harm prevention, not fairness of resource distribution.

Paternalism

⚫Paternalism involves making decisions for someone “for their own good.”

⚫The nurse is protecting confidentiality, not overriding patient choice.

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Answer 8

Correct Answers:

Autonomy

Rationale :

💎 Autonomy means the client has the right to make informed decisions about their own care.

💎 The nurse provides balanced information: benefits outweigh discomfort, but emphasizes it is ultimately the client’s choice.

💎 This supports informed consent by respecting personal values and preferences.

💎 Autonomy requires truthfulness, clarity, and freedom from coercion.

💎 The nurse is empowering the client to decide after receiving appropriate education.

Justice

💎Justice focuses on fair distribution of resources and equal care.

💎The scenario is about individual decision-making rights.

Nonmaleficence

💎Nonmaleficence is avoiding harm, but the nurse is specifically emphasizing choice.

💎The key concept presented is the client’s right to decide.

Beneficence

💎Beneficence means acting for the patient’s good, such as encouraging prevention.

💎The defining feature here is respecting the patient’s decision authority.

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Answer 9

Correct Answers:

“Delegation permits a designated individual to meet a goal on your behalf."

Rationale :

🌟 Delegation means transferring the responsibility to perform a task while the nurse retains accountability for the outcome.

🌟 It allows another qualified person to complete a task to achieve a patient-care goal efficiently.

🌟 Effective delegation improves workflow and helps ensure timely completion of essential care.

🌟 It supports safe staffing by matching tasks to appropriate team members’ scope and skills.

🌟 The core purpose is accomplishing care goals through assigned support, not avoiding responsibility.

“Delegation promotes discharge teaching activities for clients."

🌟Discharge teaching is typically an RN responsibility and not the defining purpose of delegation.

🌟Delegation is broader—assigning tasks to meet goals safely.

“Delegation provides appropriate resources for the client."

🌟Providing resources relates more to coordination and care planning.

🌟Delegation specifically refers to assigning tasks to another individual.

“Delegation decreases health care costs."

🌟Cost reduction may occur, but it is not the primary purpose.

🌟The primary goal is safe, efficient completion of care tasks.

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Answer 10

Correct Answers:

“I need to talk to you about the unit policies regarding client assignments."

Rationale :

🔷 This response is professional, nonjudgmental, and policy-based, which supports constructive problem-solving.

🔷 When an AP refuses a task, the nurse should clarify expectations, scope, and unit assignment procedures.

🔷 Discussing policy helps determine whether the refusal is due to misunderstanding, workload, competency, or safety concerns.

🔷 It also reinforces that delegation is tied to client needs and unit standards, not personal preference.

🔷 Addressing the issue calmly supports teamwork while maintaining accountability for client care.

“You always get your choice of assignment and don't work your fair share."

🔷This is accusatory and escalates conflict rather than resolving the issue.

🔷It does not address policy, safety, or role expectations.

“I have to let the director of nursing know about this situation.”

🔷Immediate escalation is usually inappropriate before first attempting direct communication and clarification.

🔷The nurse should assess the reason for refusal and refer to policy first.

“I feel you are being inconsiderate of the other team members."

🔷This focuses on emotions and blame, not the practical issue of safe task completion.

🔷It can damage teamwork and does not clarify expectations.

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QLexNursing

2 :
Following a tornado. a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge?

3 :
A coworker puts an arm around a nurse and says, "l bet you are a great lover." Which of the following is an appropriate response by the nurse?

4 :
When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

5 :
A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?

6 :
A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

7 :
A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?

9 :
A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?

10 :
A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make?

QLexNursing

2 : Following a tornado. a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge?

3 : A coworker puts an arm around a nurse and says, "l bet you are a great lover." Which of the following is an appropriate response by the nurse?

4 : When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

5 : A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?

6 : A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

7 : A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?

9 : A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?

10 : A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make?

2 :
Following a tornado. a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge?

3 :
A coworker puts an arm around a nurse and says, "l bet you are a great lover." Which of the following is an appropriate response by the nurse?

4 :
When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

5 :
A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?

6 :
A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

7 :
A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?

9 :
A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?

10 :
A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make?