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Question 1 of 5.

The charge nurse is reviewing events that staff nurses experienced during the shift. Which events require an incident/occurrence report to be completed? Select all that apply.

A. Client determined brain dead was taken off life support

B. Client with alcohol intoxication physically assaulted a nurse

C. Serum troponin level was prescribed but never obtained

D. Staff nurse did not present for work and did not notify management

E. Visitor fell and refused care in the emergency department

Explanation: Assault, missed lab tests, and staff no-show are reportable incidents due to safety, care quality, and staffing issues. Brain death withdrawal follows protocol, and a visitor's fall with refused care is less reportable.

Question 2 of 5.

The nurse approaches a 4-year-old boy to administer a medication. The child has no identification armband. Which action is most appropriate?

A. Check the room and bed number the child is in with the room and bed number on the medication order and administer the medication if they agree

B. Ask the child what his name is before administering the medication

C. Ask the child if his name is George (the name on the medication order) and administer the medication if the child says that is his name

D. Ask the adults at the bedside what the child's name is and administer the medication if the adults verify the name of the child

Explanation: Verifying the child's identity with adults at the bedside ensures safety, as children may not reliably confirm their own identity, and room/bed numbers are not sufficient for identification.

Question 3 of 5.

The nurse is caring for an adult who has atrial fibrillation and osteoporosis. Atenolol is prescribed. The nurse should expect that this medication was prescribed to:

A. decrease elevated blood pressure.

B. decrease inflammation.

C. relieve pain.

D. slow the heart rate.

Explanation: Atenolol, a beta-blocker, is used in atrial fibrillation to control heart rate, reducing rapid ventricular response.

Question 4 of 5.

A father brings his 17-year-old son to a walk-in clinic. The client reports a sudden severe headache. He has a temperature of 104°F and a purple rash. What is the best action for the nurse at this time?

A. Prepare for a throat culture

B. Schedule him for an appointment later in the day

C. Isolate and alert the physician immediately

D. Obtain a urine specimen

Explanation: Symptoms suggest meningococcal meningitis, a medical emergency requiring isolation and immediate physician notification.

Question 5 of 5.

Which nursing action is essential in the care of an adult following a left side cardiac catheterization?

A. Keep the client NPO for two hours.

B. Ask the client about a shellfish allergy.

C. Check pulses proximal to the insertion site.

D. Check the insertion site for bleeding.

Explanation: Checking the insertion site for bleeding is critical post-catheterization to detect hematoma or hemorrhage, ensuring patient safety.

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