vSim Questions

The nurse comes into the room and observes Edith Jacobson moaning and guarding her leg. What should the nurse do next?

Administer pain medication Rationale: The nurse should administer the medication after completing a pain and respiratory assessment.

When performing hand hygiene, when is it necessary to use soap and water instead of an alcohol-based hand rub?

After using the restroom Rationale: Wash with soap and water when hands are visibly soiled or contaminated with body fluids, when exposure to potential spore-forming pathogens is suspected or proven, and after the restroom.

What would be a priority nursing diagnosis for Edith Jacobson related to her psychosocial needs?

Anxiety

Which intervention ordered for Mr. Griffin poses the greatest risk for injury?

Daily complete blood count (CBC) Rationale: The daily blood draw for the CBC is most problematic since bleeding at the site may occur.

Which statement by the nurse indicates a need for further education related to a focused neurovascular assessment of Edith Jacobson?

I am going to check the pulses in your unaffected limb. Rationale: A neurovascular assessment on Edith Jacobson would include assessing for changes in circulation, oxygenation, and nerve function. The nurse should check peripheral pulses for presence, rate, and quality on both limbs and compare.

Antiembolism stockings often have an inspection window. Which statement by the nurse indicates understanding of the purpose of the inspection window?

I will place the inspection window on top of the foot so I can easily access capillary refill, temperature, and pulses of the patient's feet.

When following the proper procedure for removing gloves that are a part of contact precautions, where should the first removed inverted glove be stored while the second glove is being removed?

In the palm of the gloved hand

Which nursing interventions will have the greatest impact on minimizing the spread of methicillin-resistant Staphylococcus aureus (MRSA) among patients on a surgical unit? (Select all that apply.)

Instituting meticulous handwashing technique. Implementing standard precautions. Using appropriate personal protective equipment (PPE). Rationale: The nurse can minimize the spread of MRSA by implementing effective handwashing techniques and standard precautions, and by using appropriate PPEs.

Mr. Griffin is receiving enoxaparin sodium therapy. Which assessment data would the nurse report to the patient's health care provider to ensure his postoperative safety?

Moderate amount of gum bleeding after completing oral hygiene. Rationale: The nurse should report the information concerning the bleeding gums to the health care provider since it indicates a possible complication of the enoxaparin therapy.

Edith Jacobson has been taking raloxifene for her osteoporosis. What is the priority nursing consideration for raloxifene related to the patient's current hip fracture?

Monitor for blood clot formation.

What is the final step in removing personal protective equipment (PPE) when caring for a patient requiring droplet precautions?

Perform hand hygiene Rationale: The final step in the process of removing PPEs for any type of precautions is proper hand hygiene.

Mr. Griffin's surgical care includes anticoagulation therapy. Which diagnostic blood count indicates a risk for spontaneous bleeding and should be reported to his health care provider immediately?

Platelet of <50,000/ul Rationale: A platelet count below 50,000/ul can cause spontaneous bleeding.

What complications is Edith Jacobson at risk for because of her age and hip fracture? (Select all that apply.)

Pressure ulcers, mental deterioration, and pneumonia Rationale: Pneumonia, pressure ulcers, and mental deterioration are all risk factors for the patient due to her hip fracture.

What actions are appropriate when donning personal protection equipment (PPE) for contact isolation? (Select all that apply.)

Put on gown, being sure to securely tie or fasten. Perform hand hygiene. Don gloves.

When considering hand hygiene, which action will best remove a possible microorganism reservoir?

Removing any rings Rationale: Rings can serve as places for microorganisms to hide, and should be removed prior to hand washing and donning of gloves.

Which piece of personal protection equipment (PPE) should be removed only after leaving the patient's room?

Respiratory mask Rationale: Except for a respirator mask, remove all personal protective equipment at the patient's doorway or in the anteroom. Remove a respirator mask after leaving the patient's room and closing the door.

What is the priority outcome for Edith Jacobson in relationship to her hip fracture?

The patient will be able to walk with an assistive device without the fear of falling

Edith Jacobson needs to be frequently repositioned. Why should the task take two people?

To prevent additional injury to the patient

What should the nurse anticipate needing to teach Edith Jacobson before discharge in relationship to her hip fracture and mobility?

Use of assistive devices such as a walker Rationale: The nurse should anticipate the need to teach the patient how to use any assistive devices she will be using at home and, after that education, should ask the patient to correctly demonstrate their use.

Which fall precautions should the nurse establish for Edith Jacobson after repositioning?

a) Remind the patient that she is at high risk for falls due to her medications. b) Educate the patient to use the call light if she needs to get up. c) Make the call light easily accessible.