Safe and Effective Care Environment 2

Question 1

A nurse notices a colleague administered the wrong dose of insulin to a client. The client is currently asymptomatic. What is the nurse's first action?

Accepted Answer

Assess the client for adverse effects from the insulin overdose

Answer

Complete the incident report before doing anything else

Answer

Confront the colleague about the error in front of the client

Answer

Administer orange juice to all clients on the unit as a precaution

Question 2

A nurse is preparing to administer a blood transfusion. Which action by the nurse best prevents a transfusion reaction?

Accepted Answer

Have two licensed nurses verify client identity and blood compatibility at the bedside

Answer

Prime the IV tubing with normal saline only

Answer

Pre-medicate all clients with diphenhydramine before every transfusion

Answer

Hang the blood product within 4 hours of removal from the blood bank

Question 3

A nurse is working on a medical-surgical unit when a fire alarm activates. What is the correct sequence of actions using the RACE acronym?

Accepted Answer

Rescue, Alarm, Confine, Extinguish/Evacuate

Answer

Alarm, Rescue, Extinguish, Confine

Answer

Run, Alert, Call, Evacuate

Answer

Rescue, Alert all staff, Call 911, Escape

Question 4

A client on a medical-surgical unit is placed on Contact Precautions for C. difficile infection. Which PPE should the nurse don before entering the room?

Accepted Answer

Gloves and gown, with hand washing using soap and water

Answer

Gloves only — gowns are not required for C. difficile

Answer

N95 respirator, gloves, and gown

Answer

Surgical mask and gloves, using alcohol-based hand sanitizer

Question 5

A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is appropriate for the nurse to delegate?

Accepted Answer

Measuring and recording vital signs on a stable post-op client

Answer

Assessing a client's pain level and response to analgesics

Answer

Teaching a client how to use an incentive spirometer

Answer

Developing a plan of care for a newly admitted client

Question 6

A nurse discovers a client has been receiving the wrong IV fluid for the past two hours. The client is stable. After stopping the incorrect fluid, what should the nurse do next?

Accepted Answer

Notify the provider of the error and current client status

Answer

Complete the incident report before calling the provider

Answer

Ask the charge nurse to handle the situation

Answer

Document the error in the chart and monitor the client for 1 hour