Question

A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?

Answer 1

Correct Answers:

Activate the fire alarm

Rationale :

🔶Following the RACE protocol (Rescue, Alarm, Contain, Extinguish), the next step after rescuing the client is to activate the fire alarm to alert others and initiate the facility’s emergency response.

This ensures that the appropriate personnel respond to contain and extinguish the fire.
Attempting to extinguish the fire without alerting others delays necessary backup and poses risk.
Removing all clients prematurely can lead to chaos and is not the immediate next action.

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Answer 2

Correct Answers:

Identify the medication name and dosage administered to the client in the report.
Include the time the medication error occurred in the report

Rationale :

📌Identify the medication name and dosage administered to the client in the report;

An incident report is a factual, nonjudgmental record of an event that deviated from standard care, such as a medication error.
Identify the medication name and dosage administered to the client in the report.
The nurse must include objective, detailed information, including the name and exact dose of the medication involved in the error.
This allows for accurate evaluation, root cause analysis, and implementation of corrective action.
Leaving out such information compromises the utility of the report.

📌Include the time the medication error occurred in the report;

The timing of the error is essential in understanding when the event occurred and determining whether there was a delay in recognition or response.
This information is used in quality improvement and patient safety reviews, and it helps track patterns or system issues (e.g., shift changes, understaffing).
Timeliness is a key component of effective incident reporting.

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Answer 3

Correct Answers:

Requesting a referral for the client to attend reminiscent therapy sessions

Rationale :

⭐Advocacy involves acting in the client’s best interest to promote well-being.

⭐Referring a client with early-stage Alzheimer’s to reminiscent therapy supports cognitive function, emotional health, and social engagement, reflecting advocacy.

⭐The other choices are important aspects of care but fall under routine nursing responsibilities rather than advocacy.

⭐Advocating for therapeutic interventions is central to patient-centered care.

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Answer 4

Correct Answers:

A nurse explains to a client's family that a DNR order includes withholding comfort measures.

Rationale :

◼A DNR (Do Not Resuscitate) order means that life-saving interventions like CPR or intubation are withheld in the event of cardiac or respiratory arrest, but comfort measures must always be provided.

◼Withholding them reflects a misunderstanding of ethical obligations and patient rights.

◼The other options reflect appropriate ethical conduct, such as respecting moral objections and providing symptom relief in palliative care.

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Answer 5

Correct Answers:

Administer a bronchodilator two times a day for child who has cystic fibrosis.

Rationale :

✅Children with cystic fibrosis require bronchodilator therapy before airway clearance techniques, typically more than twice daily to optimize breathing and secretion removal.

✅ Administering it only twice daily may be inadequate for symptom management.

✅The other interventions align with standard pediatric care protocols and do not require revision.

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Answer 6

Correct Answers:

Provide the client with written information in their spoken language.

Rationale :

🌞Providing written educational materials in the client’s primary language enhances comprehension, autonomy, and safety.

🌞Using family as interpreters is discouraged due to confidentiality risks and potential miscommunication.

🌞Speaking slowly or using medical jargon does not ensure understanding.

🌞Clear written materials support client education and decision-making.

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Answer 7

Correct Answers:

Gonorrhea

Rationale :

🔸Gonorrhea is a reportable communicable disease and must be reported to the health department to track outbreaks and ensure partner notification and treatment.

🔸Other conditions listed, such as HPV, trichomoniasis, and candidiasis, are not required by law to be reported.

🔸Accurate reporting helps reduce public health risks.

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Answer 8

Correct Answers:

Submit an incident report to the risk manager
Document a factual account of the incident.
Identify all witnesses to the incident.

Rationale :

🎯Submit an incident report to the risk manager;

When a nurse witnesses a breach in procedure, especially involving a controlled substance, the first step is to submit an incident report to the risk management team.
Incident reports serve as documentation for safety issues and potential liability concerns.
By submitting the report, the nurse helps the facility to assess and address the incident in a structured and legal manner.
Risk managers use these reports to identify patterns and prevent future errors, ensuring that legal and regulatory compliance is maintained.

🎯 Document a factual account of the incident;

A factual account means that the nurse should document exactly what was witnessed, without judgment or opinion.
This includes a clear description of the actions taken by the coworker and any other details like the medication name, dosage, and time.
This documentation should be as objective as possible to ensure the accuracy and integrity of the report.
It is important to document immediately to avoid loss of detail and provide a clear record of what transpired.

🎯 Identify all witnesses to the incident;

Identifying witnesses to the incident is crucial for corroborating the events and ensuring that the incident is fully understood.
Witnesses can provide additional perspectives or evidence to support the factual account.
This will help during any investigation or disciplinary review if necessary.
It's essential for the nurse to document the names and roles of any individuals who observed the event to ensure a complete report.

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Answer 9

Correct Answers:

Prepare to administer antibiotics to the client.

Rationale :

✔Cutaneous anthrax is treated with antibiotics like ciprofloxacin or doxycycline. It is not a viral infection, so antivirals are ineffective.

✔Airborne precautions like N95 masks are unnecessary unless the anthrax is inhalational.

✔A surgical mask during transport may be standard, but antibiotic administration is the primary treatment priority.

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Answer 10

Correct Answers:

Encourage staff to participate in quality improvement projects

Rationale :

⭐Quality improvement (QI) initiatives help identify inefficiencies and enhance outcomes, which reduces costs.

⭐ Involving staff in QI fosters engagement, accountability, and innovation in care delivery.

⭐Budget planning is important but not within the nurse’s immediate role.

⭐Overstaffing increases costs and may not be necessary.

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RN Leadership 2023 Exam 1

No.

1 : A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?

2 : A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? (Select all that apply.)

3 : A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?

4 : A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?

5 : A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?

6 : A nurse is teaching a client who speaks a different language than the nurse about medications. Which of the following actions should the nurse take?

7 : A nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department?

8 : A nurse witnesses a coworker not following facility procedure when discarding the unused portion of a controlled substance. Which of the following actions should the nurse take? (Select all that apply.)

9 : A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take?

10 : A nurse manager is attending a meeting about the cost of health care. Which of the following measures should the nurse implement to reduce the cost of treatment in the acute care setting?

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