Management of Care 3

Question 1

A nurse is reviewing an incident report after a client fell in the hallway. Which statement about incident reports is correct?

Accepted Answer

The incident report is an internal quality improvement tool and should not be mentioned in the chart

Answer

Incident reports are internal quality improvement documents used to analyze and prevent adverse events. They should not be referenced in the medical record, as this can make them discoverable in litigation. The event itself is charted in the medical record.

Question 2

A nurse is caring for a client who has been placed in restraints per physician order. Which action is required by The Joint Commission standards?

Accepted Answer

The nurse must assess the restrained client and offer release every 2 hours

Answer

The Joint Commission and CMS require that restrained clients be assessed at least every 2 hours. This includes checking circulation, skin integrity, repositioning, offering release, toileting, and ROM exercises.

Question 3

A nurse is participating in a root cause analysis (RCA) following a medication error that reached a client. Which statement best describes the purpose of an RCA?

Accepted Answer

To identify systemic factors and process failures that contributed to the error

Answer

Root cause analysis is a structured quality improvement process that examines the system-level factors, processes, and conditions that contributed to an adverse event — not to assign individual blame, but to prevent recurrence.

Question 4

A nurse receives a call from a person identifying themselves as the client's employer, asking for information about the client's hospitalization. Which response is most appropriate?

Accepted Answer

Decline to confirm or deny the client's presence and explain that information is confidential

Answer

Under HIPAA, the nurse cannot confirm or deny a client's presence in the facility to unauthorized parties. Disclosing that a client is hospitalized, even without clinical details, is a violation of confidentiality.

Question 5

A nurse is planning care for a client admitted with heart failure. Using Maslow's Hierarchy of Needs, which nursing diagnosis has the highest priority?

Accepted Answer

Impaired gas exchange related to fluid accumulation in the lungs

Answer

Impaired gas exchange is a physiological survival need and takes highest priority according to Maslow's Hierarchy. It represents an immediate threat to oxygenation (airway/breathing), which supersedes all higher-level needs.

NCLEX Practice Test

NCLEX Practice Test

Management of Care 3