[Audio] SINGAPORE NURSING BOARD IMPORTANT QUESTION AND ANSWERS.
[Audio] 1) A nurse observes a staff member telling an older adult client that if the client does not take prescribed oral medications, dessert will be withheld. The nurse reports the behavior of the staff member as A. assault. B. battery. C. Malpractice. D. negligence.
[Audio] RATIONALE: Assault is a deliberate threat that the client believes could be carried through, or an unjustifiable attempt or threat to touch a person without consent that results in fear of immediate harm. Battery is unlawful touching of another person. Malpractice is a type of negligence in which any unreasonable act or professional misconduct results in injury to the client. Negligence is the omission of doing something that a reasonable person, led by those ordinary considerations that ordinarily regulate human affairs, would do or doing something another reasonable person would not do..
[Audio] 2) A new employee to a long-term care facility asks the nurse if pictures of the residents may be taken. The appropriate response is, "Pictures A. cannot be published without the resident's or guardian's permission." B. may only be taken by the family" C. can be published if the residents are not identified." D. will not violate the right to privacy when taken discreetly".
[Audio] Rationale:The right to privacy includes the publishing of pictures or any other information about a client without the client's or guardian's permission. The nurse has the responsibility to advocate for and protect the client's privacy. Pictures may be taken in a long-term care facility for the purpose of placing the photograph in the client's medical record or on the medication administration record..
[Audio] 3) An older adult client receives a gift of boxed chocolate candy. The client has dementia and does not understand that the candy is the client's and what it is. The nurse should A. tell the client the candy is the client's and offer a piece B. offer the candy to the other clients. C. sends the candy home with the client's family. D. throw the candy away, as the client is unable to eat it..
[Audio] Rationale:When a client with dementia does not recognize that the candy gift belongs to the client, the nurse should take every opportunity to get the client to enjoy it. The candy is a gift and the personal property of the client. The nurse cannot take the candy. This could constitute larceny..
[Audio] 4) Based on an understanding of the legal liability in health care, a nurse who fails to monitor the bowel movement pattern of an older adult client, which leads to an impaction, has committed which of the following? A. Misfeasance B. Malpractice C. Assault D. Negligence.
[Audio] Rationale:Negligence is the omission or commission of an act that departs from the acceptable and reasonable standards of practice. The nurse is expected to monitor the elimination patterns of clients. A nurse that fails to monitor a client's bowel movement pattern and the client develops an impaction is accused of negligence..
[Audio] 5) A nurse allowed an older adult who is confused to hold onto her purse. Later, the client was receiving oxygen by nasal prongs and attempted to light a cigarette with a cigarette lighter from the purse. An explosion, fire, and injury subsequently resulted. The case goes to court and the nurse is charged with which of the following? A. Negligence B. Battery C. Criminal negligence D. Malfeasance.
[Audio] Rationale:Criminal negligence is the disregard of protecting the safety of another person. The nurse has the responsibility to protect the client. In this case, the nurse failed to protect the client with oxygen from lighting cigarettes with a lighter and sustaining injury..
[Audio] 6) An older adult client tells the nurse that the client has human immunodeficiency virus (HIV). The nurse should A. document this information in the client's chart. B. tell the client's physician. C. inform the health care team who will come in contact with the client. D. encourage the client to disclose this information to the client's physician..
[Audio] Rationale:The nurse must protect the client's right to privacy of health care information. Documenting a client's HIV status in the client's chart, telling the client's physician, and informing the health care team who will come in contact with the client all violate the client's right to privacy..
[Audio] 7) The nurse caring for an older adult tears the skin of the client while removing a piece of tape. The skin is attached to the upper arm and to the tape. The nurse cuts the attached part of the skin with a scissors in order to remove the tape. The nurse fails to understand that if harm comes to the client during the act of cutting the skin with the scissors, which of the following could the nurse be charged with? A. Malpractice B. Negligence C. Acceptable practice D. Assault.
[Audio] Rationale:Cutting the skin of a client with a scissors could be considered a medical procedure and not within the scope of nursing practice. A charge of malpractice could result. Malpractice is a type of negligence in which any unreasonable act or professional misconduct results in injury to the client. Negligence is the omission or commission of an act.
[Audio] 8) The nurse caring for an older adult client soiled with feces fails to clean and bathe the client, leaving the client for another staff member to care for. Another nurse reports this nurse as guilty of A. nonmaleficence. B. negligence. C. malpractice. D. assault..
[Audio] 9) Which of the following should the nurse include when teaching a class on restraint application in the older adult? A. Restraints should be removed and reapplied every 4 hours B. Place a client with extremity restraints in a prone position to ensure safety C. physician must evaluate a client within one hour after restraints are applied in an emergency situation D. client should have a belt restraint on at all times as a safety precaution.
[Audio] Rationale The least restrictive type of restraint should be used. If restraints are used in an emergency situation, a physician must evaluate the client within one hour after the restraint is applied. Restraints should be reassessed every hour and removed every two hours. Wrist and ankle restraints should not be applied with the client in a prone position because there is an increased risk for aspiration. The client should be placed in a supine position. A belt restraint should not be used just because the client is an older adult and without justification. This is considered false imprisonment..
[Audio] 10) The nurse should include which of the following in the plan of care for a client who is confused, combative, bedridden, and has a vest restraint? A. Securely tie the straps of the vest restraint to the side rails of the bed B. Crisscross the vest in the front and tie the vest with a quick-release knot C. Remove the client's gown before applying the vest to ensure a snug fit D. Provide hygienic care around the vest, taking care not to untie or remove the vest.
[Audio] Rationale:A vest restraint should be crisscrossed in the front and tied with a quick-release knot. The restraint should be applied over the client's clothes to prevent friction on the skin. A restraint should never be tied to the side rails of the bed. This poses the riskof strangulation..
[Audio] 11) Which priority intervention should the nurse implement to help prevent pressure ulcers in the client who is on strict bed rest? A. Provide adequate skin care for the client. B. Turn the client every 2 hours or more often. C. Ensure sufficient nutritional intake. D. Use pressure-relieving devices such as waterbeds..
[Audio] Rationale: The priority intervention to prevent skin impairment is frequent position changes along with skin care and nutritional support..
[Audio] 12) The nurse is assisting the client to use a cane when ambulating. Rank in order of performance the interventions the nurse would take. A. Request the client to move the cane forward. B. Move the weaker leg one step forward. C. Ensure the client places the cane in the strong hand. D. Apply a gait's belt around the client's waist..
[Audio] Rationale: The gait belt is applied to ensure safety of the patient and the person assisting the client to ambulate..
[Audio] 13) Which intervention should the nurse implement first for the client with a fractured femur who is suspected of having a fat embolism? A. Assess the client's bilateral breath sounds. B. Encourage the client to cough and deep breathe C. Administer oxygen via nasal cannula. D. Prepare to administer intravenous heparin therapy..
[Audio] Rationale: Oxygen must be administered to treat hypoxia, which occurs after a fat embolism; therefore, this is the nurse's first intervention..
[Audio] 14) The client with an electrical burn is brought to the emergency department (ED). The entrance wound is on the right hand and the exit wound is on the left foot. Which intervention should the nurse implement first? A. Place sterile gauze on the entrance and exit wounds. B. Assess the client's vital signs. C. Monitor the client's pulse oximetery. D. Place the client on cardiac telemetry..
[Audio] Rationale: The electrical current in the body bounces off bone and goes through muscle. The heart is a muscle; therefore, the priority intervention is for the nurse to apply cardiac monitors to assess for lethal dysrythmias that may occur..
[Audio] 15) The nurse is using an electric patient "Hoyer" lift to transfer the client from the bed to a stretcher. Which priority intervention should the nurse implement? A. Have two staff members assist when using the lift. B. Ensure the client is correctly placed in the lift prior to moving C. Lift the client slowly off the bed when turning on the lift. D. Ensure the stretcher is in the correct position and locked..
[Audio] Rationale: This is priority because the safety of the client must be ensured. If the client is not placed correctly in the lift sleeve, the client could fall.Electric lifts are powered either through a standard electrical outlet or by a rechargeable battery. The lifting is completely controlled through a hand control, eliminating any physical exertion by the caregiver..
[Audio] 16) The nurse is assessing the functional ability ofa client using the Katz Index of Activities of Daily Living (ADLs). Whichassessment grade would require thenurse to delegate feeding, bathing, and toileting to the unlicensed assistive personnel (UAP)? A. Katz Index of ADLs grade A. B. Katz Index of ADLs grade C. C. Katz Index of ADLS grade E. D. Katz Index of ADLs grade G..
[Audio] Rationale: Grade G indicates the client is dependent in all six functions including bathing, feeding, toileting, continence, dressing, and transferring. This client would require the nurse to delegate activities of daily living to the UAP.
[Audio] 17) The client has cellulitis on the right lower leg. Which intervention should the nurse implement? A. Place the client's right arm in the dependent position. B. Apply warm moist heat to the affected area. C. Wash the affected area with anti staphylococcal Soap. D. Wrap the right arm with ACE bandages..
[Audio] Rationale: Moist heat, immobilization elevation, and systemic antibiotics are the treatments for cellulitis,which is an inflammation of subcutaneous tissue..
[Audio] 18) The unlicensed assistive personnel(UAP) is transferring the client from the bed to the chair. Which interventions should the nurse ensure the UAP implements during this procedure? Rank in order of priority. A. Assist the client to sit when the client's legs touch the edge of the chair. B. Place the wheelchair at an angle on the client's strong side. C. Assist the client to stand and put strong hand on the wheelchair armrest. D. Lock the wheelchair brakes and secure the chair position..
[Audio] Rationale: The brakes should be locked so the chair will not move during the transfer..
[Audio] 19) The nurse is caring for a client diagnosed with a full-thickness burn over the right lower extremity. Which task should the nurse delegate to the UAP? A. Instruct the UAP to check the client's right dorsalis pedal pulse. B. Ask the UAP to cleanse the client's dentures an place in the container C. Request the UAP to perform passive range-of-motion (ROM) exercises. D. Tell the UAP to keep the client's right leg in the dependent position..
[Audio] Rationale: The UAP can clean the client's dentures, so this task should be delegated..
[Audio] 20) The client is admitted to the emergency department (ED) with a third-degree burn over the front of both legs. Which priority intervention should the nurse implement? A. Maintain sterile environment when caring for the client. B. Insert two large-bore intravenous access routes. C. Administer intravenous antibiotic therapy. D. Assess the client's pain level on a 1 to 10 pain scale..
[Audio] Rationale: The priority intervention in the first 24 hours for the client with a third degree burn is maintaining intravascular volume so the client will not die from hypovolemic shock..
[Audio] 21) The nurse is discussing alternative medication (CAM) with a client on the rehabilitation unit. Which therapies should the nurse discuss with the client? Select all that apply. A. Acupuncture. B. Guided imagery. C. ompression sequential devices. D. Music therapy..
[Audio] Rationale: Acupuncture is traditional Chinese medicine, which involves the use of sharp, thin needles that are inserted in the body at very specific points and is believed to adjust and alter the body's energy flow into healthier patterns..
[Audio] 22) The nurse tells the client, "I am going to refer you to the vocational counselor." The client asks the nurse, "Why are you making this referral?" Which statement is the nurse's best response? A. "The counselor will assist you with job placement, training, or further education." B. "The counselor specializes in rehabilitative medicine and will help you get better." C. "The counselor will help develop your fine motor skills to help perform ADLs." D. "The counselor will help you continue or develop hobbies or interests".
[Audio] Rationale: This is the reason for referring a client to a vocational counselor..
[Audio] 23) The nurse is assessing the client's daily schedule and habits. Which question is most appropriate for the nurse to ask the client? A. "Do you have a family member who can assist you when you go home?" B. "What time do you prefer bathing and do you take a tub bath or a shower? C. Do you have insurance to help with the cost of rehabilitation?" D. "Do you have concerns about the care you arereceiving here?".
[Audio] Rationale: Assessment of daily schedules and habits includes questions concerning hygiene practices, eating, elimination, sexual activity, sleep, work, exercise, and recreational activities..
[Audio] 24) The home health (HH) nurse has arranged for a home health aide (HHA) to assist a 79-year-old client diagnosed with Alzheimer's disease. Which interventions should the nurse delegate to the HHA? Select all that apply. A. Weigh the client once a week and document the weight on the patient record. B. Stay with the client twice a week while the significant other (SO) goes out to run errands. C. Take and record the client's vital signs. D. Take the client to the bank and store to perform personal business..
[Audio] Rationale: The HHA is capable of weighing a client and documenting the finding..
[Audio] 25) The nurse is at the local mall and a young woman starts having shortness of breath, has hives on her face and arms, and is complaining of itching. Which intervention should the nurse implement first? A. Tell a by-stander to call 911 immediately. B. Ask the woman if she has an EpiPen. C. Check the client for a medical alert bracelet. D. Place a soft cushion under the client's head..