TTL's Day 6 & 7

The nurse has forgotten to document something. Going to the chart, the nurse finds that several people have added entries since the nurse's previous shift. Which choice contains the correct instruction for late documentation? A. Write current date and time and write, "Late entry for (date and time of shift missed)." B. Do not put in the missing data but be more careful the next time. C. Draw one line through the nurse's previous entry and rewrite an entry with the additional data and label entry as "Out of Sequence." D. Rewrite the nurse's last entry and all entries after it.

A A nurse who forgets to document an entry during a shift should write the current date and time in the next available space and mark it as a late entry. It is important to document all care, even if added as a late entry. For legal purposes, information previously recorded should not be crossed out. Rewriting entries is not recommended because it creates confusing duplicate information.

Which action should be taken when transporting a patient with TB outside the room? A. Have the patient wear a surgical mask B. Instruct the patient to use a basin when coughing up sputum C. Wear a fitted respirator mask and have the patient wear a surgical mask D. Notify the outside department of the need to wear respirators when the patient arrives

A A surgical mask prevents TB transmission from the patient to personnel or others. The patient should be instructed to use a tissue when coughing up sputum. Health care personnel do not need to wear a respirator mask if the patient is wearing a surgical mask. Outside department health care personnel do not need to wear a respirator mask if the patient is wearing a surgical mask.

A 5-year-old child cries every time a health care team member enters the TB isolation room. Which action should be taken in this situation? A. Actively engage the child's family in the explanation of any procedures. B. Remove the mask for a short period so the child can see the health care team member's face. C. Apply the respirator mask to the child so that the health care team member does not need to wear the mask. D. Explain to the child's family that the child is probably tired from his or her stay.

A Actively involving the child's family in the explanation of any procedures helps to ease the child's fears. The health care team member must wear the respirator mask at all times when in the child's room to prevent disease transmission. A TB respirator mask on the child would not prevent expulsion of droplet nuclei; additionally, applying a fitted mask to a child would be very frightening for the child. Although the child may be tired, the child is most likely crying because of fear related to the unfamiliar environment, masks, and procedures.

The health care team member is providing care to a pediatric patient in isolation. What action can the health care team member perform to reassure the child? A. Show the child all barrier precaution equipment. B. Any barrier precaution equipment should be kept from view. C. The child should see the providers' faces only after the provider dons PPE. D. Involvement of the child's family in explanations should be minimal.

A All barrier precautions should be shown to the child. Health care personnel should let the child see their faces before applying the mask so that the child does not become frightened. Ensure that the child's family is actively involved in any explanations.

A patient with pulmonary TB is being admitted to the unit. Which type of precautions should be implemented? A. Standard and airborne precautions B. Droplet precautions C. Wound and standard precautions D. Contact precautions

A Any special isolation precautions should be used in addition to standard precautions. The health care team member should use airborne precautions for a patient with a known or suspected serious illness that is transmitted by small-droplet nuclei, such as pulmonary TB. Droplet precautions should be used for a patient with an illness that is transmitted by large-particle droplets. Contact precautions should be used for a patient who is known or suspected to have an illness that is easily transmitted by direct patient contact or by contact with items in the patient's environment. Wound precautions do not prevent the transmission of a pulmonary infection.

An older adult is in need of a hearing aid. What risk factor makes the completely-in-canal hearing aid a poor choice for this patient? A. Poor dexterity B. Need for discretion C. Lack of cerumen production D. Accurate visual acuity

A Because the completely-in-canal hearing aid is smaller, it is more difficult to manipulate, and may present challenges for the patient with poor dexterity. Improper placement may result in poor hearing or infection. The completely-in-canal hearing aid is more discrete. It is generally a poor choice for a patient with excessive cerumen production because it accumulates the most cerumen. Accurate visual acuity may assist in handling the hearing aid, making this device a good choice.

Which of the following sequences is correct when doffing PPE? A. Disinfect outer gloves, remove apron, disinfect outer gloves. B. Disinfect outer gloves, remove apron, remove boot or shoe covers. C. Disinfect outer gloves, remove outer gloves, remove apron. D. Remove outer gloves, remove apron, disinfect inner gloves.

A Before each step in the doffing process, the gloves should be disinfected to remove any possible contamination and minimize the risk of touching the skin or PPE with contaminated gloves. Removing the apron and then removing the boot or shoe covers without disinfecting the gloves puts the staff member at risk of self-contamination with soiled gloves. The outer gloves are disinfected before each step of the PPE removal process but are not removed before removing the apron to maintain an extra layer of protection during the doffing process.

The nurse is assessing a new patient with a wound. The assessment indicates that the wound is covered in black tissue. What does the appearance of black tissue indicate? A. Full-thickness tissue destruction B. Infection C. Granulation tissue D. Recent surgical procedure

A Black or brown tissue is eschar, which represents full-thickness tissue destruction. Black is used to describe necrotic tissue or desiccated tissue such as tendon. Yellow tissue represents nonviable tissue and in some cases the presence of an infection. Red tissue represents the presence of granulation tissue. Black tissue does not indicate a recent surgery.

A patient with dentures has a history of tobacco and alcohol abuse. The nurse's need for further education regarding oral assessment techniques is indicated when the nurse performs which action? A. Leaves dentures in the mouth for fear of losing them B. Uses a tongue blade to lightly depress the tongue C. Uses a penlight to look inside the mouth D. Determines if the dentures fit well and are comfortable when in place

A Dentures should be removed in order to visualize the entire mouth. Ill-fitting dentures chronically irritate the oral mucosa and gums. This can lead to breakdown. A tongue blade assists in positioning the tongue out of the visual field. A penlight facilitates visualization.

What problem do enlarged, fixed, inflamed, or tender lymph nodes suggest? A. Local infection B. Allergy C. Recreational drug use D. Stress

A Enlarged, fixed, inflamed, or tender lymph nodes may occur as a result of infection, systemic disease, or a malignancy. Stress, allergy, and recreational drug use do not result in enlarged, fixed, inflamed, or tender lymph nodes.

What is the purpose of using moisture-retentive dressings? A. Enhance debridement B. Treat infection C. Protect the skin D. Treat maceration

A For patients with a low infection risk, the use of moisture-retentive dressings enhances debridement. These moisture-retentive dressings may include moist dressings, as well as hydrocolloids, hydrogels, or alginates. If the wound is infected, topical antimicrobials are used. Moisture-retentive dressings are not used to protect the skin or treat maceration.

Which statement is true regarding a powdered air-purifying respirator? A. A powdered air-purifying respirator (PAPR) has the same filtering properties as a mask-type respirator. B. A PAPR is donned as part of standard precautions. C. A PAPR is removed by grasping the top ties first and pulling away from the face. D. A PAPR must be fit-tested prior to first use.

A If facial hair or unusual facial features make it difficult to fit a mask-type respirator properly, a powered air-purifying respirator (PAPR) may be used. A PAPR is not a standard face mask and cannot be removed by grasping ties. A PAPR is a type of respirator used when caring for patients known or suspected to have tuberculosis and are part of isolation precautions. This type of respirator covers the head and uses a blower to move air through the filter and into the face piece, helmet, or hood. A PAPR does not require fit testing before use.

The nurse is assessing the patient for skin breakdown. The nurse notices an area of erythema on the patient's buttock and should press on the area to detect which condition? A. Blanching B. Reactive hyperemia C. Skin turgor D. Maceration

A If the area of erythema does not blanch (turn lighter with finger pressure), this may indicate tissue damage. Reactive hyperemia is the blood rushing into the tissue and causing the redness. Maceration is softening of tissue caused by steeping in a fluid. There is no indication here that the patient has been lying in fluid (e.g., urine or feces). Skin turgor is not usually evaluated on the buttocks.

The patient has Stage 2 pressure injuries on the buttocks and hips and is on a pressure-redistribution mattress while in bed. The nurse obtains an order to get the patient out of bed as tolerated. The nurse decides to get the patient up in a chair for meals and to put the patient back in bed 1 hour after meals to rest. What else should the nurse do? A. Consider use of a pressure-reducing pad for the chair. B. Consider keeping the patient in a chair for the entire shift. C. Limit the patient's visitors so that the patient can rest. D. Get an order for ambulation.

A If the patient requires a pressure-reduction surface for the bed, an appropriate pressure-reduction surface should also be considered for the chair. Placing a patient in a chair for the entire shift is not much better than keeping the patient in bed all day. The patient may not be quite ready for ambulation yet. Visitors can be a source of encouragement for patients as well as a distraction from the routine in the health care setting.

Isolation precautions may be discontinued when the likelihood of infectious tuberculosis is deemed negligible. In order to remove the patient from isolation precautions, which laboratory results need to be confirmed? A. Three consecutive AFB sputum specimens are negative B. Two recent AFB sputum specimens are negative C. The most recent AFB sputum specimen is negative D. The AFB specimens are negative and were obtained hourly for three consecutive hours.

A In order the remove a patient from isolation precautions, the patient must have three consecutive AFB sputum specimens that are negative or the patient has another diagnosis that explains the current clinical status of the patient. Each of the specimens should be collected 8 to 24 hours apart.

Which interventions should the nurse perform to prevent excessive drying of the corneas when preparing to bathe an unconscious patient? A. Instill prescribed eyedrops and keep the patient's eyes closed with eye patches. B. Tape both eyelids closed after instilling the prescribed eye ointment. C. Instill saline eyedrops and provide frequent cleansing of the uncovered eyes. D. Cleanse the eyelids, instill the prescribed eye ointment, and then tape the eyes closed.

A Patients who are unconscious have lost the normal protective corneal reflex of blinking, increasing the risk of corneal drying, abrasions, and eye infections; instilling prescribed eyedrops and keeping the eyes closed maintain eye moisture and prevent injury. Eye patches should be used instead of tape to keep the eyes closed. Tape may harm the sensitive skin around the eyes when it is removed.

To measure the depth of a PI or wound, what should the nurse do? A. Insert a cotton-tipped applicator into the deepest section of the PI or wound. B. Document the original depth of the PI or wound and subtract 0.5 cm for each day of healing. C. Insert a cotton-tipped applicator into three sections of the PI or wound and calculate the average depth. D. Estimate the depth of the PI or wound based on the number of days of healing.

A To measure the depth of a PI or wound, the nurse should insert a moistened cotton-tipped applicator into the deepest section of the PI or wound and measure the depth. Estimating the PI or wound depth based on the original depth does not provide an accurate PI or wound depth measurement. The PI or wound depth should be obtained only at the deepest section of the PI or wound, not in three different sections of the PI or wound. PI or wound depth cannot be estimated; it must be measured.

The patient complains of a whistling sound from the hearing aid when removing it from the ear. Which action should be taken? A. Advise the patient to turn off the volume before removing the hearing aid. B. Demonstrate how to twist the hearing aid during removal to prevent the whistling. C. Place a request for the biomedical engineering department to check the hearing aid. D. Explain to the patient that this is a normal occurrence that cannot be prevented.

A Turning the hearing aid volume off before removal prevents feedback (whistling) during removal. The hearing aid is to be removed following the natural contour of the ear to prevent injury to the ear. Whistling is an obnoxious stimulus, not a normal occurrence, and it can be prevented by turning off the hearing aid before removal. The manufacturing company should evaluate any issues with the hearing aid, not the biomedical engineering department.

An 88-year-old patient who is diagnosed with dementia frequently becomes agitated and aggressive with caregivers. What is the most appropriate approach for bathing this patient? A. Assisting the patient with a shower B. Providing a complete bed bath C. Providing a disposable bed bath D. Avoiding bathing until the patient becomes more relaxed

C A disposable bath offers a patient with dementia an alternative method of bathing and may be appropriate because of ease of use, reduced bathing time, and greater patient comfort. A shower is not a safe option for an older adult patient with cognitive impairment. This patient may become agitated if given a complete bed bath. An established routine for regular bathing is important for an older adult patient with cognitive impairment; therefore, waiting until the patient relaxes may interrupt his or her established routine.

After caring for a patient with Ebola, the nurse demonstrates an understanding of the safety measures by performing which action while still in the patient's room? A. Removing gloves and disinfecting hands by washing with soap and water B. Removing gloves and disinfecting hands with ABHR C. Disinfecting gloves with either an EPA-registered disinfectant wipe or ABHR D. Removing the outer gloves and donning another pair of outer gloves

C Disinfecting gloves with either an EPA-registered disinfectant wipe or ABHR is a required step after caring for the patient and after each step of the doffing process. This step is essential to prevent cross-contamination to the other components of the PPE. The gloves should never be removed while in the patient's room because of the increased risk of a breach. The gloves are removed only after disinfection with either an EPA-registered disinfectant wipe or ABHR and only when the trained observer monitors the nurse's actions.

How should the nurse correct a mistake made while recording the patient's vital signs on a flow sheet? A. Use correction fluid and write over the error. B. Scratch out the error and rewrite the notation. C. Follow the organization's practice for correcting documentation errors. D. Discard the flow sheet and record the notations on a new sheet. Rationale: Following the organization's practice for correcting documentation errors limits liability e

C Following the organization's practice for correcting documentation errors limits liability exposure and ensures consistency, which promotes patient safety. Scratching out an error may make the record illegible or may appear as if the nurse is trying to hide information or deface the record. Using correction fluid in a patient record can make it look as if the nurse is trying to hide information. All documentation that has been placed in a patient's record should be maintained as part of the permanent record.

A patient is admitted to the trauma unit wearing a cervical collar. What precautions should be taken by the nurse? A. Remove the collar every shift to assess the skin. B. Massage the skin under the collar. C. Assess the skin around and beneath the collar. D. Place the patient in the supine position.

C Inspection of the skin and bony prominences should occur at least daily. All bony prominences should be inspected, as well as skin around and beneath orthopedic devices, such as the cervical collar, braces, or casts. The cervical collar should not be removed without a physician's order or per the organization's practice. Any reddened or discolored areas should be palpated but not massaged. The patient should be placed in a position of comfort or as ordered by the practitioner until the orthopedic device is removed.

Why is it important to assess visual acuity in older adults? A. It indicates the amount of fatigue that the patient is experiencing. B. It suggests future deterioration of the patient's vision. C. It indicates the level of assistance that the patient requires with activities of daily living. D. It implies the need to place the patient on skin and wound precautions.

C Measuring visual acuity helps the nurse determine how safely the patient is able to function independently at home. Measurement does not predict future changes in visual acuity. Assessment of visual acuity is not a measurement of fatigue and does not determine the need for skin precautions.

The nurse notices an area of redness on the patient's hip. The nurse presses the area and finds that it is an area of nonreactive erythema. What condition does this indicate? A. Stage 2 pressure injury B. Blanchable erythema C. Stage 1 pressure injury D. Deep-tissue pressure injury

C Nonblanchable erythema or skin temperature changes may be an important early indicator of a Stage 1 pressure injury. Blanchable erythema blanches when it is pressed. Stage 2 pressure injuries involve partial-thickness loss of dermis and presents as a shallow open injury with a red-pink wound bed without slough. Stage 2 may also present as an intact or open or ruptured serum-filled blister. A deep tissue pressure injury is a purple or maroon localized area of discolored intact skin or blood-filled blister because of damage to the underlying soft tissue from pressure or shear.

A patient has a Stage 2 pressure injury on the coccyx. The patient is being turned every 2 hours and is wearing elbow and heel protectors. What is needed to protect the patient from further injury? A. Photographs need to be taken to document the progress of the ulcer. B. The patient needs to begin receiving total parenteral nutrition. C. The heel and elbow protectors should be removed at least daily to assess skin integrity. D. A massage should be given in reddened areas over bony prominences.

C Skin and bony prominences should be inspected at least daily. Inspecting the skin on a regular basis provides data for each nurse to determine if there is further skin breakdown. Devices, shoes, socks, and heel and elbow protectors should be removed for the skin inspection. Photographs may be taken but do not prevent further breakdown. Total parenteral nutrition is used only if the patient is unable to take in nutrition by other means. Areas of nonblanchable erythema or discolored areas may indicate that deeper tissue damage is present. Massage in this area may worsen the inflammation by further damaging underlying blood vessels.

When removing equipment from a patient's isolation room, which item is best to use for disinfecting the equipment? A. A clean cloth B. Hydrogen peroxide C. Organization-approved disinfectant D. Povidone-iodine

C Systematic disinfection of equipment with an organization-approved disinfectant minimizes the risk of spreading infectious organisms among patients. Using povidone-iodine or hydrogen peroxide and wiping the equipment with a clean cloth are not acceptable methods for disinfecting equipment.

Which hearing assistance device is most effective for a patient with sensorineural deafness? A. Conventional hearing aid B. In-the-canal device C. Cochlear implant D. Behind-the-ear hearing aid

C The cochlear implant consists of an internal implant that receives signals from a separate external processor and transmits them electrically to the auditory nerve. This makes this device the most effective assistance device for a patient with sensorineural deafness. Conventional, in-the-canal, and behind-the-ear hearing aids will not pick up signals effectively to allow a patient with sensorineural deafness to hear clearly.

When caring for a patient with a wound, which unexpected outcome should the nurse report? A. Red wound bed B. Granulation C. Undermining D. Serous drainage

C The development of tunneling or undermining is reported to the practitioner as an unexpected outcome and may change the treatment plan. Granulation or a red wound bed is an expected outcome and should be included in the wound documentation. Wound exudate is documented with an amount, color, and consistency. Serous drainage is not an unexpected outcome.

When leaving a patient's room and preparing to remove disposable isolation garments, what is the appropriate order of PPE removal to prevent cross-contamination? A. Gloves, mask, eye protection, and gown B. Gown, gloves, mask, and eye protection C. Gown and gloves, eye protection, and mask or respirator D. Gown, eye protection, mask, and gloves

C There is only one correct sequence for removing PPE to prevent the health care team member from coming into contact with contaminated materials. Gloves and gown should be removed first, then eye protection, and then the mask or respirator. All other scenarios increase the risk of contact with contaminated material.

What is the best action for the health care team to take to reduce exposure of team members to infectious microorganisms? A. Enlist multiple personnel to provide care for a patient on isolation precautions. B. Implement a plan for multiple, short trips into the patient room C. Reduce the number of trips in and out of the patient room D. Designate only two health care team members to restock the patient room at the end of the shift.

C Trips in and out of the room should be reduced to limit the exposure of health care team members to microorganisms. Multiple trips, including those of short duration, increase the exposure of the health care team member to infectious microorganisms. The room should be stocked by enlisting another person on the health care team to hand in new supplies without entering the room.

A nurse is preparing to admit a patient diagnosed with or suspected of Ebola. Which of the following statements regarding the isolation plan demonstrates that the nurse has a good understanding of the Ebola virus? A. "Contact, droplet, airborne, and standard precautions are required to protect health care personnel." B. "Contact, droplet, airborne, standard precautions, and special PPE precautions are required to protect health care personnel." C. "Contact, airborne, standard precautions, and special PPE precautions are required to protect health care personnel." D. "Contact, droplet, standard precautions, and special PPE precautions are required to protect health care personnel."

B Contact, droplet, airborne, standard precautions, and special PPE precautions are required to protect health care personnel caring for a patient suspected of or diagnosed with Ebola. Although the Ebola virus is not airborne, the CDC has recommended using both Tier 1 (standard precautions) and all components of Tier 2 (contact, droplet, and airborne) precautions as well as special PPE precautions as a safety measure to protect health care personnel because of the highly contagious nature of the virus. Not implementing all of the required precautions places health care personnel at risk.

The nurse finds a patient sitting alone and crying. Which is the most objective statement for correct documentation? A. "Patient appears depressed." B. "Patient sits alone and cries in room, states 'I feel bad' when questioned." C. "Patient sits alone and appears upset." D. "Patient does not interact with others, obviously upset."

B Documenting that the "patient sits alone and cries in room, states 'I feel bad' when questioned" provides an objective assessment of the nurse's observation and the patient's response. Stating that the patient "appears" depressed is a subjective opinion. The nurse's subjective interpretation that the patient "appears" upset does not provide the objective detail that is necessary in documentation. The nursing interpretation that the patient is "obviously" upset does not provide an objective description of the patient's demeanor.

The nurse is caring for a patient with a pressure injury. Upon assessment, the nurse notes a foul odor. What can this indicate? A. Maceration B. Infection C. Granulation D. Slough

B Drainage that has a foul odor may indicate infection and should be reported to the practitioner. Maceration indicates excess moisture of the periwound. Granulation is a red appearance of the wound bed and indicates healing. Slough is yellow colored tissue.

Which statement is true regarding the use and removal of a face mask? A. Masks are donned as part of standard precautions. B. Masks are donned as part of droplet precautions. C. Masks are removed by grasping the top ties first and pulling away from the face. D. Masks are removed by grasping the outer surface of the mask first.

B Droplet precautions are standard precautions plus a mask. One method of removal is to grasp the bottom ties or elastics first and then the top ties or elastics and pull the mask away from the face. The outer surface of the mask should not be touched as it is considered contaminated.

The nurse observes an area of nonblanchable erythema on the patient's back. The nurse realizes that this is caused by a decrease in circulation. What action should the nurse take to relieve the erythema? A. Cover the area with a transparent dressing B. Arrange for more frequent position changes C. Apply a dry sterile dressing D. Provide a 5-minute massage

B Early detection of pressure indicates a need for more frequent position changes or the use of a pressure-relief device. Areas of nonblanchable erythema or discolored areas may indicate that deeper tissue damage is present. Massaging this area may worsen the inflammation by damaging underlying blood vessels. Because there is no break in the skin, dressings are not required.

A patient is suspected of having TB. Which is the most appropriate action to take? A. Implement airborne precautions. B. Keep the door of the room closed. C. Wear a surgical mask into the room. D. Instruct the patient to wear a respirator mask when family visits.

B Isolation for a patient with suspected or confirmed TB includes placing the patient on airborne precautions in a negative-pressure AIIR with the door closed as much as possible. Contact isolation is not sufficient for TB, which requires airborne precautions. A surgical mask is not sufficient for TB, which requires a respirator mask because only high-efficiency particulate respirator masks have the ability to filter particles at a 95% or better efficiency. The patient should not wear a respirator mask because it does not prevent expulsion of droplet nuclei into the air.

Pressure injury prevention measures should be implemented for a patient with which Braden score? A. Less than or equal to 16 B. Less than or equal to 18 C. Less than or equal to 20 D. Less than or equal to 24

B Patients are at risk for skin breakdown/development of pressure injuries with a Braden score of 18 or less. The other numbers are not the risk cutoff scores for the Braden scale.

Which is the most important safety measure the nurse can take when providing care for the patient during a complete bed bath? A. Allowing the patient to sit unassisted on the side of the bed B. Raising the side rail and lowering the bed if the nurse leaves the bedside C. Lowering the bed and leaving the side rail down for the patient to bathe himself or herself D. Washing the affected or injured extremity before cleansing the unaffected extremity

B Raising the side rail and lowering the bed maintains the patient's safety if the nurse leaves the bedside. The patient who requires a complete bed bath should never be left alone and unassisted on the side of the bed or with the side rails lowered. If an extremity is injured or has reduced mobility, the nurse should care for the unaffected side first.

Which type of drainage indicates fresh bleeding? A. Serous drainage B. Sanguineous drainage C. Serosanguineous drainage D. Purulent drainage

B Sanguineous (bright red) drainage indicates fresh bleeding. Serous drainage is clear, like plasma. Serosanguineous drainage is pink. Purulent drainage is thick and yellow, pale green, tan, or white.

What is the correct way to remove a PAPR or respirator mask? A. Grasp the top elastic and pull the mask down below chin level B. Grasp the bottom elastic and then the top elastic and pull the mask away from the face. C. Gently grasp the outer surface of the mask and pull away from the face D. Grasp the outer surface of the mask and both elastics and pull the mask away from the face.

B The correct way to remove the mask is to grasp the bottom elastic and then the top elastic and pull the mask away from the face. The front of the mask is considered to be contaminated and should not be touched. Touching only the elastic protects ungloved hands from contamination.

What is the goal of managing a red granulated PI or wound? A. Dry the PI or wound bed B. Maintain moist environment C. Debride the tissue D. Soften the tissue

B The goal of managing a red granulated PI or wound is to select a dressing that maintains a clean and moist PI or wound environment and minimizes damage to healing tissue. Red tissue represents granulation. The red color is the result of an increasing number of new blood vessels in the PI or wound and is considered healthy. The goal of PI or wound management is not to dry the PI or wound bed or to debride or soften the tissue.

Which action should be performed when assisting the patient to insert a hearing aid? A. Gently pull the ear to straighten the ear canal. B. Insert the pointed end of the ear mold into the ear canal. C. Turn on the volume before inserting the hearing aid. D. Place the blue color-coded hearing aid into the right ear.

B The hearing aid should be placed into the ear with the pointed end of the ear mold fitting into the ear canal. The nurse should follow the natural ear contour to guide the aid into place. Pulling on the ear may distort the canal and make insertion more difficult. The volume should not be turned on until after insertion, and then it should be adjusted gradually to prevent discomfort. The blue color-coded hearing aid goes into the left ear; the red color-coded hearing aid goes into the right ear.

The nurse is preparing to administer an injection to a patient. What is the purpose of donning gloves before the procedure? A. Gloves minimize the transfer of microorganisms. B. Gloves act as a barrier to reduce the risk of exposure to blood. C. Gloves reduce the risk of needlestick injury. D. Gloves provide protection to the patient.

B The use of gloves during the administration of injections acts as a barrier to reduce the risk of exposure to blood. The use of gloves does not decrease the risk of needlestick injury. The primary purpose of wearing gloves is not for patient protection during an injection. The use of gloves minimizes the transfer of microorganisms for a patient in isolation but is not the primary purpose of donning gloves for an injection.

Upon investigating a patient's report of decreased hearing acuity, cerumen is observed over the receiver of the hearing aid. Which intervention is the most appropriate? A. Leave the cerumen as is because it is a natural occurrence. B. Insert the supplied cleaning appliance in the receiver to clean out the cerumen. C. Wash the receiver with soap and water and then pat it dry. D. Gently wipe off the receiver to remove the cerumen.

D Cerumen affects the functioning of the hearing aid; therefore, it should be gently wiped off. The receiver is easily damaged, and nothing should ever be inserted into the receiver port; even the cleaning appliance supplied with the hearing aid should not be inserted into the receiver. Washing is inappropriate because the hearing aid, including the receiver, must stay dry at all times.

During the morning assessment, it is observed that the patient's hearing acuity has decreased from the prior morning. After having the patient remove the hearing aid, which action should be taken? A. Use a sharp object to clean the hearing aid. B. Increase the volume of the hearing aid. C. Wash the hearing aid with soap and water. D. Inspect openings in the hearing aid for cerumen.

D Cerumen may block sound from the receiver, decreasing the patient's hearing acuity. If cerumen is occluding openings on the hearing aid, increasing the volume will not resolve the problem. The hearing aid should not be washed with soap and water; the appropriate method for cleaning is to use a wax loop or other device supplied with the hearing aid.

When preparing to enter the room of a patient who has a Clostridium difficile infection, the health care team member should follow contact precautions. These precautions would include the use of which item(s)? A. A negative-airflow room B. Gloves only C. A mask or respirator D. Gloves and a gown

D Contact precautions require the use of both gloves and a gown, not just gloves alone. Because Clostridium difficile is not an airborne disease, components of the barrier protection used with airborne precautions, such as a negative-airflow room and a mask or respirator, are ineffective barriers.

Which statement by a patient with a hearing aid indicates the need for more education? A. "I will keep the batteries away from my young grandson." B. "I will store my hearing aid with a desiccant when I take it out." C. "I will make sure to see my audiologist every year to follow up. D. "I will clean my hearing aid with alcohol each evening when I take it out."

D Hearing aids should be kept away from water, alcohol, hairspray, cologne, perspiration, rain, and snow to avoid damage. Batteries should be kept away from young children because they can be toxic if swallowed. Hearing aids should be stored with a desiccant to prevent moisture from entering. Patients should be encouraged to follow-up with an audiologist or hearing aid specialist at least annually.

Which statement is true regarding use and storage of respirators? A. Respirators are disposable and should be used only once. B. Respirators should be stored in the most convenient location for future use C. Respirators may be stored in a humid location in direct sunlight D. Respirators are disposable and the same individual may use them more than once.

D Respirators are disposable, but the same individual may use them more than once. Respirators should be stored between uses in a plastic bag. The respirators should be stored in a dry place, and out of direct sunlight.

Which patient has the lowest risk of skin impairment? A. A 12-year-old male in skeletal traction B. A 27-year-old male with a chest tube C. A 45-year-old female with large breasts D. A 49-year-old female with hypertension

D Risks for skin impairment include reduced mobility, reduced sensation, nutritional and hydration alterations, excessive moisture on the skin (particularly on skin surfaces that rub against each other), vascular insufficiencies, external devices applied to or around the skin, old age, shearing and friction, and incontinence. Hypertension is not an identified risk factors for skin impairment. Skeletal traction creates immobility, a risk factor for skin impairment. Large breasts can lead to rubbing and skin friction, a risk factor for skin impairment. A chest tube limits the patient's ability to move about in bed, a risk factor for skin impairment.

It is important for the health care team member to understand that standard precautions should be used for every patient. Which circumstance is a patient care situation in which gloves are needed? A. Recording vital signs B. Preparing a patient's medications C. Offering the patient a meal tray D. Touching blood, body fluids, or mucous membranes

D Standard precautions require that gloves be worn when touching blood, body fluid, secretions, excretions, nonintact skin, mucous membranes, or contaminated items. Wearing gloves appropriately, not just during sterile procedures, is an important component of standard precautions. Gloves are needed for medication preparation only when the medications are caustic. Gloves should be removed and hand hygiene performed before recording vital signs in the patient's record. Gloves are not necessary when providing a meal tray to a patient.

A nurse is preparing to enter the room of a patient diagnosed with Ebola. Which of the following statements indicates the nurse needs more education? A. "The donning and doffing of PPE requires supervision by a trained observer." B. "The principle of ensuring no skin is exposed before entering the room of a patient with Ebola provides protection for the health care giver." C. "Strict monitoring is required for 21 days after an exposure to the Ebola virus." D. "A PAPR is required when caring for a patient with Ebola."

D The CDC's updated guidelines instruct health care personnel to wear either a PAPR or an N95 respirator. Both the N95 and the PAPR provide equal protection, and staff members should choose the one they are most comfortable wearing. Supervision of both the donning and doffing processes is an essential component to ensure the safety of health care personnel. The trained observer uses a standardized checklist to guide health care personnel and observes each step of the process. A key step in the donning process is for the trained observer to ensure that no skin is exposed. Improper donning can result in exposed areas of skin, which increases the staff member's risk of coming in contact with the Ebola virus. The incubation period (time interval from infection with the virus to onset of symptoms) is within 21 days. Humans are not infectious until they develop symptoms. First symptoms are the sudden onset of fever, fatigue, muscle pain, headache, and sore throat.

Which technique is the correct method for assessing lymph nodes? A. Palpate lymph nodes using the pads of the middle three fingers in a circular motion. B. Palpate over the frontal areas in a circular motion. C. Instruct the patient to put his or her chin down and inspect the area where lymph nodes are distributed. D. Stand behind the patient and have him or her swallow while palpating the lymph nodes.

A Palpating lymph nodes using the pads of the middle three fingers in a circular motion provides the most effective method of assessment. Lymph nodes are not located in the frontal areas. The nurse should inspect the lymph nodes with the chin raised (not down) and head tilted slightly. The nurse should also face or stand to the side of the patient (not behind) and palpate gently in a rotary motion for superficial lymph nodes using the pads of the middle three fingers. Instructing the patient to swallow is done when assessing the thyroid and neck anatomy.

If not contraindicated, when positioning the patient in bed, the head of the bed should be in which position? A. A 30-degree angle or less B. A 45-degree angle or higher C. A 90-degree angle D. The high-Fowler position

A Pressure is reduced to the sacral area when the head of the bed is not at a high elevation (30 degrees or less). A 45-degree angle or higher, or the high-Fowler position, increases pressure to the sacral area.

The nurse is assessing the patient's pressure injury and finds that some subcutaneous fat is showing, but no muscle tissue is exposed. What stage is the pressure injury? A. Stage 3 B. Stage 2 C. Stage 4 D. Stage 1

A This is a Stage 3 (full-thickness) pressure injury because it extends to subcutaneous tissue but not muscle, tendon, or bone. A Stage 4 pressure injury would have muscle, tendon, or bone exposed. A Stage 1 or Stage 2 pressure injury is partial thickness and would not have visible subcutaneous tissue.

An older patient with skin breakdown is being discharged home. What additional teaching does the nurse provide at discharge? A. Use of the Braden scale B. Use of a timer for implementation of pressure-relief techniques C. Massage techniques D. Ambulation safety

B The patient and family should be taught that position changes need to occur on a frequent basis. Suggest to the patient that using a watch with a timer would help him or her remember to complete pressure-relief techniques. The Braden scale is a specialized tool that is used by nursing practitioners. Discolored areas of the skin may indicate that deeper tissue damage is present and massage is contraindicated. Ambulation safety may be discussed at discharge but is not the primary concern associated with skin breakdown.

Where might a patient with an NG tube in place experience a skin breakdown? A. Tongue and lips B. Nares C. Neck D. Ears

B The patient with an NG tube would be prone to developing skin breakdown of the nares because that is where the tube rests while in position. An orogastric tube, oral airway, or endotracheal tube can cause breakdown of the tongue and lips. A cervical collar can cause skin breakdown around the neck, as can tracheostomy tube ties. Skin breakdown of the ears can be caused by an oxygen cannula or a pillow.

An older adult patient has reported an inability to understand what others are saying, even though stating an ability to hear. Which hearing aid is appropriate for this type of hearing loss? A. BTE hearing aid B. Cochlear implant C. CIC hearing aid D. Programmable hearing aid

D A programmable hearing aid amplifies some sound frequencies more than others; therefore, it accommodates differences in hearing loss and helps make speech more understandable. Cochlear implants are for patients with profound damage to the structure of the inner ear. The CIC and the BTE hearing aids are different styles, but they are not programmable.

A patient reports moderate pain after undergoing a hemorrhoidectomy. Which is a priority nursing intervention to decrease the patient's pain? A. Administering an antiinflammatory medication B. Providing a medicated bath with oatmeal C. Providing an ice pack D. Providing a sitz bath

D A sitz bath cleanses and reduces pain and inflammation in the perineal and anal areas and is used for the patient who has undergone rectal or perineal surgery or childbirth. Oatmeal baths are for soothing irritated skin. Ice packs may cause more local discomfort. Antiinflammatory medications require a practitioner's order.

During an examination of facial features, the nurse observes that the patient exhibits asymmetry of the mouth. What problem may asymmetric facial features indicate? A. Infectious process B. Stress disorder C. Fatigue D. Neurologic disorder

D Asymmetry can be a sign of a neurologic disorder, such as paralysis or a malignancy. Fatigue, stress, and infection are not manifested by facial asymmetry.

The nurse has just completed a dressing change. Which entry is the most complete and appropriate to write in the nurse's notes? A. "Wound is healing well." B. "Wound edges seem to be coming together." C. "Wound appears clean and dry." D. "Wound is 3 cm in diameter, no drainage noted."

D Describing the exact size and drainage amount provides an objective assessment as required for nursing documentation. "Appears" and "seem" are subjective terms and are not appropriate for nursing documentation. "Well" is also a subjective term, and the wound should be better described by specific details and measurements.

The health care team member is caring for a patient in isolation. Which item requires double bagging prior to exiting the patient's room? A. Blood specimens B. Contaminated dressings C. Used syringes D. Heavily soiled linen

D Heavily soiled linen or heavy, wet trash is to be double bagged. Single bags can be used for soiled articles if they are sturdy and impervious to moisture. Blood specimens are transported in a biohazard bag. Syringes are not placed in the trash.

When evaluating a PI or wound, what should the nurse know about the periwound assessment? A. It is included for all immobile patients. B. It is performed only when the PI or wound is surrounded with a rash. C. It is performed only when the patient has a PI or wound drain. D. It provides clues to the effectiveness of PI or wound treatment.

D Periwound assessment provides clues to the effectiveness of the wound treatment. Periwound assessment is done for all wounds, with or without a drain or rash, and regardless of whether the patient is mobile.

Which is the correct action to take immediately after obtaining a specimen from a patient in isolation? A. Take the specimen immediately to the laboratory and label the specimen there. B. Place all the specimens requiring ice for transport into one biohazard bag. C. Retain the original pair of donned gloves, even if soiled from obtaining the specimen. D. Label the specimen in the presence of the patient.

D The first step to take after obtaining the specimen is to label the specimen per the organization's practice in the presence of the patient. If the specimen requires ice for transport, place the specimen in a biohazard bag and then place the bag with the specimen into a second biohazard bag filled with ice slurry. If gloves become excessively soiled and further care is necessary, remove gloves, perform hand hygiene, and don new gloves.

What should a health care team member remember to do when donning a fit-tested respirator mask? A. Readjust the respirator mask frequently while in the patient's room. B. Pinch the mask and create a crimp at the bridge of the nose. C. Use a new mask each time he or she enters the patient's room. D. Place the mask over the nose, mouth, and chin and ensure that the bottom flap is pulled out completely.

D The respirator mask should be donned by placing the mask over the nose, mouth, and chin and ensuring that the bottom flap is pulled out completely. A crimp in the mask may create an air leak; the mask should be molded to the nose instead. Respirator masks are reusable, so there is no need to use a new mask each time the a health care team member enters the patient's room. If the respirator mask needs to be adjusted, the health care team member should leave the isolation area to readjust.

When preparing to enter the room of a patient suspected of having Ebola, which of the following precautions should be followed? A. Wear gloves only when touching the patient. B. Wear one pair of gloves with extended cuffs. C. Wear an N95 and a PAPR respirator with a hood. D. Wear two pairs of gloves with extended cuffs.

D Two pairs of gloves with at least one pair having extended cuffs are required to provide an extra barrier between the patient and a staff member. The cuffs minimize the risk of the gloves rolling down and exposing skin between the gown and gloves. Either an N95 or a PAPR respirator is used, not both. Both the N95 and the PAPR provide equal protection, and staff members should choose the one they are most comfortable wearing. Gloves must be worn at all times in the presence of a patient suspected of or diagnosed with Ebola because the virus is highly contagious.

During the patient's admission assessment, it is determined that even with a hearing aid the patient has difficulty understanding the conversation. Which intervention should be added to the patient's plan of care? A. Rephrase the information the patient is having difficulty understanding. B. Yell directly into the patient's hearing aid. C. Stand to the patient's right side. D. Repeat the information in a louder tone.

A Rephrasing, rather than repeating, the information is a more effective step to assist the patient in understanding what is being said. Repeating the information in a louder tone may cause the patient to become frustrated. Some patients may have difficulty understanding certain sounds. Yelling into the patient's hearing aid is not necessarily beneficial. Facing the patient, as opposed to standing to one side, is more helpful.

Upon removal of a hearing aid, a rough edge is observed on the pointed end of the ear mold of the hearing aid. This abnormality puts the patient at risk for which complication? A. Irritation of the ear canal B. Accidentally turning the hearing aid off C. Whistling from the hearing aid D. Wearing out the hearing aid battery

A Roughness of the ear mold of the hearing aid may cause irritation of the ear canal. The roughness will not accidentally turn off the hearing aid or cause whistling from the hearing aid. Roughness will also not cause excessive wear on the hearing aid battery.

A patient should be suspected of having TB if the patient has which symptoms in addition to respiratory symptoms lasting longer than 3 weeks? A. Unexplained weight loss, night sweats, fever, and a productive cough B. Jaundice, night sweats, and a persistent fever C. A fever of at least 38.1°C (100.6°F), night sweats, and a stiff neck D. Elevated amylase, nausea and vomiting, and a productive cough

A TB should be suspected in any patient with a persistent cough lasting longer than 3 weeks or longer, accompanied by chest pain, bloody sputum, unexplained weight loss or loss of appetite, fever, chills, night sweats, malaise, or fatigue. Jaundice is usually suspected with liver disease. A stiff neck is usually suspected with meningitis. Elevated amylase is suspected with pancreatic disease. Nausea and vomiting are not associated with TB.

The nurse is called to another patient's room before having the opportunity to document a medication given to a patient. Which action should the nurse take? A. Document the medication administration without delay and, if necessary, have another nurse assist the other patient. B. Write the medication name and dose administered on a piece of paper as a reminder and document it later. C. Ask another nurse to document the medication administration. D. Document all administered medications at the end of the shift.

A The nurse should make every effort to document care in a timely manner, preferably right after care is rendered, to ensure accuracy and to avoid medication errors. If the nurse documents the medication administration later, another staff member may not realize that the patient has received the medication, leading to a medication error or an error in patient care. The nurse who rendered care or made an observation is responsible for documentation of the care or observation.

A patient who is paraplegic has been admitted with a diagnosis of uncontrolled diabetes mellitus. The patient is able to move from the bed to a wheelchair with minimal assistance but always asks for assistance. The patient has an indwelling urinary drainage catheter in place draining clear yellow urine and requires manual disimpaction every other day. Even though the patient is alert and cooperative, which complication is still a high risk for the patient? A. Pressure injuries B. Urinary tract infection C. Bladder stasis D. Falls

A The patient may be at risk for any of these but is especially at risk for the development of pressure injuries. Patient characteristics that favor the development of pressure injuries include paralysis or immobilization caused by restrictive devices, sensory loss, and disorders that affect circulation (e.g., diabetes mellitus). Bladder stasis should not be a problem with an indwelling urinary drainage catheter in place. The patient is still at risk for falls, but because the patient is cooperative and asks for assistance, the risk is probably minimal. Urinary tract infection is always a risk for patients who are paraplegic, especially with catheters, but because the patient's urine is clear, the patient is probably free of infection at present.

The nurse documents the wound assessment findings, noting that the wound base is 100% red granulation tissue. Last week the wound had 40% yellow tissue and 60% red tissue. What does this finding indicate? A. The wound is healing and debridement is not needed. B. Debridement is needed to remove excess nonviable tissue. C. The wound is not healing, likely related to infection. D. Debridement is needed to stimulate wound healing.

A The wound has an increased amount of healthy red tissue, and there is no further evidence of yellow nonviable tissue. Because no yellow, nonviable tissue is present, debridement of the wound is not indicated. Red tissue indicates wound healing. No signs of infection are present. The wound is healing appropriately with the current intervention as evidenced by the reduction in nonviable tissue and the increase in healthy granulation tissue.