311 Final exam #2

Content: IV Infusion A nurse is caring for a patient getting saline though an IV. How often should the nurse be checking the IV infusion? Every hour Every day Every 4 days Never

- answer: A Rationale: The nurse needs to be checking the IV infusion every hour because they can verity the medication is still being given at a safe rate and dosage.

Which of the following is not the appropriate example for SBAR? a. Situation: the patient is not doing good. b. Background: the patient is reported having headache, and lately is confusion c. Assessment: this is what I think the problem is HTN after I took the vital signs d. Recommendations: What do you want me to do this time.

Answer: a Rationale: The situation needs to sate concisely why you need to communication the client data with that you have assessed; the example above did not provide patient name, and the specific problem that client has.

A student nurse is evaluating their client's environment for safety. Which of the following statements indicates the need for further instruction? "I will leave the urinal in the bathroom for the client" "I left the call light within the client's reach" "the bed is in the lowest position" "the room is free of clutter"

Answer: a Rationale: Urinals are used by clients who are unable to ambulate to the restroom. The urinal needs to be within reach of the client at the bedside

Content: Skin Integrity and Wound Care A nurse wants to minimize the risk of a pressure injury to a bedridden client. Which of the following interventions should she implement to do this? a. Use a foam ring or donut-type device to redistribute tissue loads b. Implement appropriate interventions to maintain dry, clean skin c. Routinely reposition the patient every 4 hours d. Assess the client's skin once a week

Answer: b Rationale: Skin damage and pressure injury development can be a result of exposure to excessive moisture. Decreased tissue tolerance occurs and increases the susceptibility to friction, shear, and pressure.

Content: Ambulation When assisting a patient with ambulating with a cane where is the best position for nurse to stand? a. Directly beside the patient on his/her weaker side. b. Directly beside the patient on his/her stronger side c. To the side and slightly behind the patient. d. Slightly behind the patient.

Answer: c Rationale: Positioning to the side and slightly behind the patient encourages the patient to stand and walk erect. It also places the nurse in a safe position if the patient should lose his or her balance or begin to fall.

A health care provider has placed an order for an extremity restraint for an adult patient. How long is the nurse allowed to leave the restraint on? A. 2 hours B.1 hour C. 4 hours D. 6 hours

Correct answer: C Rationale: If an extremity restraint is ordered by a physician for an adult patient that is at least 18 years of age, they can place the patient in restraints for 4 hours before having to renew the order after removal. Children and adolescents the ages of 9 - 17 would be placed in an order for 2-hour restraints. Children under the age of 9 would have an order for 1-hour restraints. No adult patient should be placed in an extremity restraint greater than 4 hours.

A nurse has just finished cleaning a patient's dentures, what would be the most appropriate way to store them for the patient? A. In the denture cup in hot water B. In the denture cup in cold water C. Wrap them in a paper towel D. Place them in an empty cup

Answer : B Rationale : When dentures are not in a patient's mouth they should be stored in the denture cup in cold water, unless the dentures have metal parts. Storing the dentures in cold water prevents warping of the dentures.

A nursing instructor is observing a nursing student prepare to assist a patient with dental care. What action by the nursing student requires a need for further teaching? A. Raising the bed to a working height B. Setting the equipment in the client's reach C. Allowing the patient to remain in a supine position D. Performing hand hygiene

Answer : C Rationale : Allowing a patient to remain in a supine position could result in the patient aspirating. Patient's should be in a sitting or side-lying position when brushing their teeth.

Content: Laboratory Specimen Collection When testing stool for occult blood what is the proper technique for obtaining the sample? a. Obtain two samples from different areas using the same side of the wooden applicator. b. Obtain two samples from different areas using opposite ends of the wooden applicator for each area. c. Obtain one sample from one area. d. Obtain two samples from the same area using opposite ends of the wooden applicator.

Answer b Rationale: Two separate areas of the same stool sample are tested to ensure accuracy. By using opposite ends of the wooden applicator, cross-contamination is avoided

Which of these is the correct order of events a nurse should follow when applying personal protective equipment (PPE) a. handwashing, gown, mask, eye protection, and gloves b. mask, eye protection, handwashing, gloves, and gown c. gown, mask, eye protection, handwashing, and gloves d. handwashing, gloves, gown, eye protection, and mask

Answer: A Rationale: When applying PPE, the nurse should always follow the order of: handwashing, gown, mask, eye protection, and gloves. This should preferably take place outside of the patient's room. The reverse order is always followed when removing PPE.

Content: Wound Care 1. Proper technique for preforming a wound culture includes what? a. Cleansing the wound prior to obtaining the specimen .b. Swabbing the area with the largest collection of drainage. c. Removing crusts or scabs then culturing the site beneath. d. Waiting until a dose of antibiotics is administered to obtain the specimen.

Answer: A Rationale: Wound culture specimens should be obtained from a cleansed area of the wound. Microbes responsible for infection are more likely to be found in viable tissue.

Content: Patient Identification Which identifiers for adult and pediatric inpatients are required? Select all that apply Patient Name Patient Medical Record Number/identification number Birth date.

Answer: A & B (A & B are always required, C should be done when possible, but not required) Rationale: To improve accuracy of patient identification. The use of two identifiers also helps ensure that a correct match is made between the service or treatment and the individual.

Content: Assisting a Patient with Oral Care (Skill 7:3, Module 1) What are considered unexpected findings for when assisting a patient with oral care? (Select all that apply) A: bleeding from gums B: patient expresses positivity C: dry, cracked lips D: dry mucosa E: patient's mouth and teeth are clean

Answer: A, C, D Rationale: Poor oral hygiene can be related to tooth decay, difficulty and pain swallowing, aspiration and pneumonia, (dry mucosa, thrush, cavities, ulcers, lesions, and gingivitis). The mouth should be kept moist, rinsed after meals, brushed and flossed twice a day.

Content: AIDET & Hourly Rounding The nurse is calling the health care provider about a patient's changing condition after he has just finished his hourly rounding and has done an SBAR assessment, What would the assessment include? A. Situation, background, assessment, and recommendation B. Subjective information, background, assessment, and revisions needed C. Situation, background, all vitals, and review of orders D. Summary, better plan, accurate diagnosis, and rights

A. Rationale: The other options are not the correct abbreviations even if they are necessary such as taking all vitals.

The nurse needs to collect stool for occult blood testing from 3-month-old patient. The parent ask if it can be collected from the diaper. what is the best response by the nurse? A. "only if the stool has not been contaminated by urine." B. "of course, it can be collected from diaper whenever" C. "it can be collected only from a cloth diaper" D. "it depends on how much feces the client has"

answer : A rationale : stool can be collected from a diaper for occult blood tasing only if the stool has to been contaminated by urine. It does not matter the baby use disposable or cloth diaper. Also amount of feces does not make a difference for occult blood test.

When the patient has no or few teeth, What should you use for oral care? A. Only mouthwash B. soft-bristled toothbrush with a small head C. Electrically powered toothbrush D. Damp cloth

Answer: B Rationale:Use a soft-bristled toothbrush with a small head even when the patient has no or few teeth. It is the only effective way to remove plaque and debris from the teeth, gums, and tongue.

Mr. Goldstein is incontinent of his stool and has an indwelling urinary catheter. When completing routine catheter care the nurse should... a. Don sterile gloves before cleansing the insertion site with soap and water. b. Cleanse the catheter at least three times a day and after defecation .c. Make sure the collection bag is above the level of the bladder to avoid reflux.

Rationale: a. Incorrect. Sterile gloves are necessary during insertion of the urinary catheter, but standard gloves are appropriate during routine catheter care .b. Correct. Cleaning the insertion site regularly helps decrease contamination and prevent CAUTI's especially considering Mr. Goldstein is incontinent of his stool. c. Incorrect. The collection bag should be below the level of the bladder to avoid reflux.Reference: ATI: Fundamentals for Nursing, Tenth Edition, Chapter 44, Urinary Elimination, p. 253.

Content: Monitoring IV site A nurse goes into a patient's room to check their IV site. The site looks swollen and the patient says it is painful. What might this indicate is going on with the IV. Catheter is still properly in the vein Catheter has become dislodge from the vein IV solution is flowing into the subcutaneous tissue B & C are correct

- Answer D Rationale: When the IV site appears swollen and painful it is likely the catheter is not in the correct place. This could cause the medication that is flowing to begin to flow into subcutaneous tissue.

Content: Assessing a Wound The nurse is preparing to assess a wound of a patient. Which of the following will the nurse not note of during the assessment? A. Drainage B. Texture C. Appearance D. Size

Answer: B Rationale: The nurse should not touch the wound with an unprotected hand or glove. This could cause further injury to the wound. The nurse would want to note of drainage, appearance, and size of the wound. These are pertinent to good wound care for nurses.

Skill 8-2 Cleaning a wound and applying a dressing A nurse must change a patients wound dressing after, what is the appropriate method for removing the old dressing and applying the new dressing? A. Quickly pull the dressing away from the skin to avoid prolonging patient discomfort.B. Working from the center of the bandage pull the dressing up, away from the sking. C. Pull the dressing slowly and carefully away from the skin, but do not use adhesive remover as it may contaminate the wound.D. Pull the dressing slowly away from the skin, in the direction of hair growth, use adhesive remover or saline as necessary.

Answer is D. Rationale: It is important to avoid traumatizing the surrounding skin when changing a dressing. Adhesive remover or saline may be used if the bandage is difficult to remove. This minimizes problems associated with skin stripping and patient discomfort.

A client is having trouble with their balance while walking. A cane is recommended for them to use. When the nurse is teaching the client how to use the cane she should inform them to hold the cane with: A. The hand on the side that needs support B. The hand opposite to the side that needs support C. Their dominant hand D. Which ever hand they prefer to use

Answer is: D Rationale: The client is having issues with her balance and stabilization, therefore they can use which ever hand they prefer to use for support. If they had a weaker side they would use the hand opposite to their weaker side but no weaker side was stated.

Nurse Amy is in her patient's room and in the process of checking the patient's medication with the provider's STAT medication orders when Nurse Molly comes into the room explaining there has been an emergency in another room. Nurse Amy asks Nurse Molly to finish her medication administration so she can go into the room with the emergency. What should have happened in this scenario? A Nurse Amy should have told Nurse Molly to go find the doctor/another nurse in the unit to assist with the emergency while she finished her medication administration and she would be at the emergency as fast as she could. B Nurse Amy should have ran to the emergency with Nurse Molly and come back to the medication administration another time. C Nurse Amy should have not worried about checking the medication with the order and finished the medication administration quickly, so she could run to the emergency. D Nurse Amy did the right thing by asking Nurse Molly to fill in for her medication administration.

Answer: A Rationale: Nurse Amy could not ask Nurse Molly to fill in for her because Nurse Molly would not have gone through the 6 rights of administration and 3 checks properly and herself. Nurse Amy needs to trust there are other nurses/doctors on her floor that could assist her with the emergency patient while she finishes the task she started of administering the medications properly. She also could not leave the patient she was administering the medication to because the order was STAT.

The nurse is in the client's room to administer the client's morning oral medications. Which action should the nurse take first? a)Confirm the client's identity b)Document the medications being given c)Open the unit dose packages of medications d)Pour a cup of water for the client to drink

Answer: A Rationale: The nurse should always verify the clients identity first in order to ensure that the medication administered is to the right person and also to maintain client safety.

When cleaning a wound with an approximated edges, which way would you cleanse the wound and surrounding area? A.Use a new swab or gauze for each swipe, and swipe in downward strokes B.Use the same swab or gauze, and swipe in circular motions up to two inches around the affected area C.Cleanse from the most contaminated area to the cleanest area D.Use the same swab or gauze for each swipe, and swipe in downward strokes

Answer: A Rationale: When cleaning a wound with approximated edges, you want to use a new swab with each swipe and swipe in downward motions. You want to swipe from top to bottom while using a new swipe so you will not contaminate the wound.

Content: Testing Stool for Occult Blood The nurse is preparing to perform a blood occult test on a patient. The nurse plans to properly perform this procedure by... A. Reporting a positive test to the provider. B. Applying a large amount of stool from the center of the bowel movement onto the window of the testing card. C. Labeling the specimen card and sending the collected specimen to the laboratory in a biohazard bag within the week. D. Testing the quality control section before testing the spool specimen.

Answer: A Rationale: A positive result is an abnormal finding. An abnormal findings need to be reported to the provider. Only a thin smear of specimen is needed to perform this exam. The lab should be sent out immediately, no longer than 24 hours. The quality control section should be tested after it's determined whether the stool sample is positive or negative.

Which section of the SBAR would include abnormal lab values that were done before the patient came into the hospital? A. Background B. Situation C. Recommendation D. Assessment

Answer: A Rationale: Any pertinent information related to the patient care that has already taken place should be documented in this section.

Content: Cleaning a Wound and Applying a Dry, Sterile Dressing A nurse is cleaning the wound of a patient. What is the correct way to clean a patients wound? a. From the top to the bottom and from the center to the outside b. From the bottom to the top and from the outside to the center c. From the top to the bottom and from the outside to the center d. From the bottom to the top and from the center to the outside

Answer: A Rationale: Cleaning from top to bottom and from the center to the outside ensures that you are cleaning from least contaminated area to the most contaminated area and that you are not contaminating an area that has already been cleaned.

Content: Medications After oral administration, drug action has a_________compared to other routes of administration? A. Slower onset and a more prolonged, but less potent effect B. Slower onset and a more prolonged, but more potent effect C. Faster onset and a less prolonged, but less potent effect D. Faster onset and a more prolonged, but less potent effect

Answer: A Rationale: Drugs given orally are intended for absorption in the stomach and small intestine. The oral route is the most commonly used route of administration and is usually the most convenient and comfortable route for the patient. After oral administration, drug action has a slower onset and a more prolonged, but less potent, effect compared to other routes of administration.

What all do you perform/ask the patient when taking vital signs? a. T; BP (MAP); P; R; O2 Stat; and Pain score b. T; BP; P; R; O2 Stat; and Pain score c. T; BP; P; R; O2 Stat d. T; BP (MAP); P; R; O2 Stat

Answer: A Rationale: When you do vitals on the patient you always take their temperature, blood pressure (MAP), pulse, O2 stat and you always ask what their pain score is on a scale of 0-10.

A nurse is providing oral care for a pediatric patient. Which of the following demonstrates appropriate care for a pediatric patient? A. Using a damp cloth to clean the gums of an infant, regardless of the fact that they do not have teeth B. Waiting until the patient has all of their teeth to begin flossing C. Using toothpaste high in fluoride to compensate for the patient's dietary habits of consuming excess sugary sweets D. Using more toothpaste for pediatric patients than for an adult patient due to their tendency to swallow the toothpaste

Answer: A Rationale: Flouride can be toxic if consumed. Using a larger amount of toothpaste or a toothpaste high in fluoride is not recommended due to children's tendency to swallow the toothpaste. Flossing should begin as soon as two teeth touch to reduce the likelihood of developing cavities. A damp washcloth is best practice when cleaning the gums of infants as it reduces the likelihood of irritating the gumline or causing breakdown of the gums.

When assisting a patient with a cane which side should the cane be on? a. his or her stronger sideb. closer to the nurse, since the nurse is helpingc. his or her weaker sided. Patient shouldn't use a cane

Answer: A Rationale: Holding the cane on the stronger side helps to distribute the patient's weight away from the involved side and prevents leaning. Positioning to the side and slightly behind the patient encourages the patient to stand and walk erect. It also places the nurse in a safe position if the patient should lose his or her balance or begin to fall.

A patient is thought to have Clostridium difficile infection and is asked to provide a stool specimen for culture. Which of the following actions is not appropriate when collecting a stool specimen? a. If portions of the stool include visible blood, mucus, or pus, discard of the specimen and tell the patient you will try to collect another specimen at a later time. b. After collecting the specimen, place container in a sealable biohazard bag. c. Collect as much stool as possible. d. Send specimen to the laboratory immediately.

Answer: A Rationale: If portions of the stool include visible blood, mucus, or pus, include these with the specimen. You would collect as much stool as possible, make sure the container is in a biohazard, sealable bag, and send to the laboratory immediately because a fresh specimen produces the most accurate results.

Content: Perform Safety Assessment Used During Clinical A nurse is doing a safety assessment for a patient who is considered a Fall Risk, what steps should the nurse take to ensure the room is free of hazards? A. Clear the walkway of any objects B. Keep the lighting low C. Put the patient's glasses farthest away from him D. Leave the side rails down

Answer: A Rationale: It is important to clear the walkway of any possible hazards because anything could cause the patient to fall. Keeping the lighting low would impair the patient's vision causing a potential risk. The nurse would want the patient's glasses closest to them so they can reach easily for them instead of having to get up to look for them. The nurse needs to leave the side rails up because this could be a risk for the patient falling off the bed.

Content: AIDET & Hourly Rounding Why is "Thank you" an important part of AIDET? A It is important to thank the patient to make them feel valued. B We live in the south and that is what we are supposed to do because of southern hospitality. C Thank you is not part of AIDET. D Nurses do not have to say thank you to their patient, as we assume they already know it is implied.

Answer: A Rationale: It is important to say thank you to your patient, no matter where you live. Thank you is part of AIDET. As a nurse, we should never assume when it comes to the patient.

What is an advantage for using SBAR during staff communication? A. Improves verbal communication and reduces medical errors B. Provides a complete patient health history C. Focuses on a comprehensive physical examination D. Avoids making recommendations

Answer: A Rationale: SBAR communication is concise and focused; SBAR does not include a complete patient health history. SBAR communication does not include a comprehensive physical examination.SBAR communication includes "R," which is making recommendations.

Content: Cleaning a Wound A nurse is providing care to a client who has a laceration on her left forearm. When changing the patient's dressing, the nurse notes the dressing is sticking to her forearm. In order to remove the dressing without causing damage to the patient's skin the nurse should: a. Use saline to moisten the dressing to prevent injuring the patient's skin when removing it. b. Use the push-pull method of removal by pushing the skin down then quickly pulling the dressing off in one pull. c. Use tap water to loosen the dressing from the patient's skin. d. Gently scrub at the skin to free it from the dressing.

Answer: A Rationale: Saline is the appropriate option for removing a dressing that is sticking to a patient. The push-pull method involves slowly and gently pushing the client's skin down and pulling back on the dressing until it eases off the skin. Tap water is not the correct choice for moistening the dressing when given saline as an option. Never scrub the patient's skin as it could damage their skin integrity.

A nurse is educating a student nurse about hourly rounding and AIDET. Which statement made by the student about his or her education requires further intervention from the nurse? a. "When leaving a patient's room I should keep their drinks away from them, so they don't spill and cause a fall risk." b. "I will maintain good eye contact with my client when introducing myself." c. "I will practice good hand hygiene when I enter and when I exit a patient's room." d. "The call light should be left in-reach of the patient."

Answer: A Rationale: The nurse should always keep the patients' personal items within reach, so they do not fall out of bed trying to reach them.

Content: Assisting a patient with ambulation using a cane A nurse is assisting a patient with ambulation using a cane. Which side should the patient hold the cane on? A. strong side B. weak side C. either side, depends on the patient preference

Answer: A Rationale: The patient should hold the cane on the strong side because it helps the patient prevent leaning and to distribute the weight away from the injured, or weak, side. Patient should avoid using the weak side because they would be putting weight on the weaker, or injured side.

Skill 4:1: Identifying Risks for Patient Falls Fall Prevention A nurse is evaluating a fall risk for an elderly client who lives alone. What would the nurse instruct the elderly client to do to prevent a fall risk? a.) Use nonskid mats and avoid shaggy rugs. b.) Leave all room lights on. c.) Provide ambulation device (walker, wheelchair, cane). d.) Provide the patient with a bedside commode.

Answer: A Rationale: Using nonskid mats and avoiding shaggy rugs will prevent fall risk because it will allow the elderly client to have more stability when walking through his/her home.

When should a nurse, who has tried all other methods of care, evaluate extremity restraint use to a patient. Select all that apply. a. Patient is confused and continuously pulls out IV access device b. Patient is unconscious and doesn't speak c. Patient is dangerous to self and medical personal d. Patient looks at the nurse the wrong way

Answer: A & C Rationale: Restraints may be indicated after other methods have failed to prevent patient from removing therapeutic devices(IV access devices, endotracheal tubes, oxygen, or other treatment interventions). Restraints must be applied safely and appropriately to reduce risks of injury. If a patient is at risk for injury to self or others this would be an appropriate action.

Content: Using a Pulse Oximeter/ Monitoring Oxygen Saturation What is the use for pulse oximetry? Select all that apply Titrating oxygen therapy Monitor those at risk for hyperoxia Monitor patients before surgery Monitor those receiving oxygen therapy

Answer: A & D (The uses include titrating oxygen therapy, monitoring those at risk for hypoxia, monitoring postoperative patients, and monitoring patients receiving oxygen therapy Rationale: The pulse oximeter is used to measure the arterial oxyhemoglobin saturation of arterial blood when needed

Content: Obtaining a urine specimen from an Indwelling Catheter A nurse has received an order to obtain a urine specimen from an indwelling catheter, when considering, what is the MOST important step that the nurse must not forget? a. Scrub aspiration port vigorously with alcohol or other disinfectant wipe and allow port to air dry. b. Clamp the catheter drainage tubing or bend it back on itself distal to the port. c. Slowly inject urine into the specimen container. Take care to avoid touching the syringe tip to any surface. Do not touch the edge or inside of the collection container. d.Unclamp the drainage tubing.

Answer: A ( although they are all correct, A is the most correct) Rationale: It is very important to practice aseptic technique to reduce the risk of infections. Cleaning with alcohol or other antimicrobial deters entry of microorganisms when the needle punctures the port. As health care providers, our goal is to limit infections, especially urine associated infections such as UTIs.

Skill 5-1: Administering Oral Medications A nursing student is preparing to give medications to a client under the supervision of her instructor. Which of the following actions indicate the need for further teaching? Select all that apply. A. When preparing a unit dose medication, the student opens the package in the medication room and puts it in a cup to take to the client's room. B.The student helps the client sit upright in bed before giving the medications. C. The student places a cup of pills on the client's bedside table and instructs them to take the medication when they are ready. The student leaves the client's room. D. The student immediately documents that the medication was given after she administers it.

Answer: A and C Rationale: The package of a unit dose medication should not be opened until the student/nurse is in the client's room so it can be checked as a safety measure. The student/nurse should not leave the room until all medications have been swallowed. If the student/nurse does not see the client take the pills, they cannot be recorded as administered. Helping the client sit up and documenting immediately following administration are appropriate actions.

A nurse is performing a situational assessment. Which of the followings would cause a concern? Select all that apply. a) Lose or torn carpet b) Toys on the stairs c) Firearms in the house d) Adequate lighting

Answer: A, B and C Examine the home for objects on the floor, the presence of wires or cords, objects on the steps, and loose or torn carpet. Encourage residents to keep walkways, floors, and stairs clear. Assess for the presence of firearms in the home. Provide education regarding safe storage as appropriate.

Which of the following would be an example of a Priority Nursing Problem? (select all that apply) a. Risk for bleeding b. Risk for chronic low self-esteem c. Risk for activity intolerance d. Risk for being mean

Answer: A, B, & C Rationale: A, B, & C are all on the NANDA list while D is not

Content: Monitoring an IV site and infusion A client has an IV in his right arm and is complaining of pain around the site. The nurse assesses the IV site and observes redness around the IV site. What is the appropriate action for the nurse to take? Select all that apply. Discontinue the infusion immediately Apply a moist, warm compress to the site Restart the infusion in a different site notify the provider

Answer: A, B, C Rationale: Discontinuing the infusion and moving it to a different site is indicated when a client has phlebitis. A warm, moist compress can help with the pain and redness. Notifying the provider is only indicated if the patient has a severe form of phlebitis.

Content: Implementing Alternatives to the Use of Restraints Whenever a nurse is applying restraints, which of the following is the most appropriate action? Select all that apply. A. Identify triggers or contributing factors to patients behavior. B. Implement fall precaution interventions. C. Obtain an order for restraints from provider after applying restraints. D. Explain rationale for applying restraints to patient.

Answer: A, B, D Rationale: Removing triggers and contributing factors can decrease need for restraints. Patients that have increase risk for use of restraints also have increase risk for fall. An order for restraints needs to be obtained before applying the restraints. Explaining rationale to patient can help with compliance and understanding of restraints.

A patient is pulling at their IV tubing and attempting to remove the dressing at the IV insertion site. What nursing intervention could be used before the use of restraints? (Select all that apply). __ A. IV site covered with gauze and tubing placed under top bed linen to minimize appearance. __ B. Increase rounding time to every 30 minutes, when family not present. __ C. Sedate patient with the use of medication. __ D. Seclude the patient in a room by himself. __ E. Reevaluate need for IV fluid infusion.

Answer: A, B, E Rationale: Covering the IV site and placing the tubing under linen, increasing rounding times, and reevaluating patients need for IV fluids are all alternative methods to restraints. Where as, sedating a patient with medication and secluding the patient are forms of restraining the patient, not alternative methods.

Content: Employing Seizure Precautions and Seizure Management 1. What are patients at risk for during a stroke? (Select All That Apply) A. hypoxia B. vomiting C. hypertrophy D. chronic endometritis E. pulmonary aspiration

Answer: A, B, E Rationale: During a seizure, patients are at risk for hypoxia, vomiting, and pulmonary aspiration. Patients who are at risk for seizures and those who have had a seizure(s) are often placed under seizure precautions to minimize the risk of physical injury.

While assisting a patient with ambulation, they begin to have a seizure. Which of the following actions should be taken? Select all that apply. A Remove eyeglasses and loosen any constrictive clothing B Leave the patient to go get help C Gently lower the client to the ground and lay them on their side D Call for a blanket or towel to put beneath their head Place tongue blades in their mouth to prevent choking

Answer: A, C, D Rationale: You must always stay with a patient while they are having a seizure and placing anything in their mouth would increase the risk of choking rather than prevent it. Removing eyeglasses, loosening clothing, laying them on their side, and placing a cushion underneath their head are all things that can be done to prevent any harm during this time.

Applying a extremity restraint would be a last resort for a patient. Before going to that extent, what other alternatives can you consider? (select all that apply) a. Move patient closer to nursing station. b. Administer a sedative. c. Ask a family member or significant other to stay with the patient. d. Provide adequate lighting e. Camouflage tube and other treatment sites with clothing, elastic sleeves, or bandaging.

Answer: A, C, D, E Rationale: Moving the patient closer to the nurses station allows for frequent and closer observation. Having someone stay with the patient provides companionship. appropriate lighting can reduce disruptive behavior. Camouflaging can remove or reduce the stimulus that triggers behaviors that may need the use of restraints.

BEFORE a nurse can administer oral medication to a client, the nurse must: (SELECT ALL THAT APPLY) A. Check the client's allergies B. Document the administration of the medication C. Read the MAR and select the proper medication for that client D. Remain with the client until each medication is swallowed E. Scan the client's ID band

Answer: A, C, E Rationale: Checking the client's allergies is to ensure that they are not contraindications for the medication that the nurse is administering. Reading the MAR and selecting the proper medication for the client is the first check that must be done before administering medication. Scanning the client's ID band is an additional check to ensure that the medication is given to the right client. Documentation should be completed immediately AFTER the medication has been administered. Remaining with the client would also be immediately AFTER the initial administration.

A student nurse is about to give oral medications for the first time. What statements by the student nurse indicate further guidance is necessary prior to allowing her to administer oral medications. Select all that apply.A. To save time I can prepare medications for multiple patients at once. B. I will only break scored tablets, and never extended-release medication. C. If I am delayed in giving a patient a medication, I can give them the medication at a later time. D. I can perform the third check after all medications have been prepared at the eMAR/MAR if my facility policies allow it. E. It is not necessary to remain at the bedside until the patient has swallowed each medication.

Answer: A, C, E. Rationale: Medications must be prepared for one patient at a time, only scored tablets can be broken, extended release tables should not be broken, crushed, or chewed. Patients must be given their medications on time. If a facility's policies allow the third check at the eMAR/MAR it may be performed there. Nurses must remain at the bedside until all medication is taken.

Which statement made by a student nurse about caring for a peripheral IV site and infusion best demonstrates to a nursing instructor that teaching has been successful? A: "I must palpate the IV site every one hour." B: "I will check the IV infusion every two hours." C: "The peripheral venous access dressing should be changed every 10 to 14 days or any time it is damp, loosened, or visibly soiled." D: "I will not pull the dressing perpendicular to the skin."

Answer: A. Rationale: The peripheral venous access dressing should be changed every 5-7 days or if it becomes damp, loosened, or visibly soiled. When removing the dressing, the nurse should begin at the device hub and gently pull the dressing perpendicular to the skin towards the insertion site. It is common to check the IV infusion and site every hour, or more often according to facility policy, including palpating for induration.

The nursing student is learning about assisting a patient with ambulating using a cane. Which statement indicates the student needs further teaching? A. "I have a lot of patients to look after today so I am going to delegate this task of ambulating with a cane to the UAP on shift today." B. "I will apply nonskid shoes or slippers to my patient before ambulating." C. "I will instruct my patient to use his/her strong leg first upon ambulating." D. "I will instruct my patient to hold the cane on his/her strongest side to prevent leaning."

Answer: A. Rationale: Ambulating with a cane can never be delegated to a nursing assistive personnel (NAP) or unlicensed assistive personnel (UAP).

Content: Skill 7-3: Assisting the Patient with Oral Care Which of the following is not an appropriate action when assisting a patient with oral care? A. Brush tongue firmly to ensure thorough cleaning B. Place brush at a 45-degree angle to gum line C. Offer patient petroleum jelly to lubricate lips D. When flossing, maintain 1 to 1.5 inches of floss taut between the fingers

Answer: A. Rationale: Brush tongue gently to remove coating, being sure not to stimulate the gag reflex.

A nurse is teaching a patient how to ambulating with his cane. What side of the body should the nurse instruct the patient to hold the cane on? A. Patients stronger side B. Patients side that is injured C. Patients weaker side to strengthen it D. Either side, because the patient needs to strengthen both sides evenly

Answer: A. Rationale: The patient should hold the cane on their strongest side to prevent leaning and even distribution of weight away from the weaker/injured side.

A nurse is preparing to enter the room of a client on contact precautions to administer medications. Which PPE would be appropriate for the nurse to use when providing care for the client? Select all that apply. a. Gown b. Mask c. Gloves d. Goggles

Answer: A/C Rationale: Gloves are worn to comply with standard precautions. A gown is worn to decrease the likelihood of coming into contact with the patient's blood or body fluids and to prevent the spread of disease.

A nurse is providing care to a 47-year-old female client who has recently been diagnosed with tuberculosis. Which PPE would be appropriate for the nurse to use when providing care for the client? Select all that apply. a. Gloves b. Gown c. Googles d. N95 Respirator

Answer: A/D Rationale: Either a certified high-efficiency particulate air (HEPA) filter respirator or N95 respirator must be worn when entering the room of a patient with a known or suspected airborne disease. Gloves are worn to comply with standard precautions.

Content: Patient Identification Which of the following are considered appropriate patient identifiers by the Joint Commission? Select all that apply. A) name B) social security number C) birth date D) room number E) physical location

Answer: ABC Rationale: "...defines a patient identifier as "Information directly associated with an individual that reliably identifies the individual as the person for whom the service or treatment is intended." (Theoretically, any patient could be in Room 123 or be located in the East wing of the hospital. These are not considered patient-specific because the information could change - it is not constant.

Content: Three checks and the "rights of medication administration" A nurse is administering Ibuprofen 400 mg PO every 2 hours to Sally Sue. She's offered education on the medicine and offers the right to refuse. Ms. Sue demonstrates understanding of the education, and Ms. Sue says she wants the medication. After assessing before and after giving the medication, the nurse documents that she gave the medication and moves onto her next task. What right of administration is the nurse missing? Right to inform Right Evaluation Right Dose Right to decline

Answer: B Rationale: The right evaluation was a step in the 6 rights to medication administration that was skipped during this scenario. The nurse is required to follow up with the patient 30 minutes after administering the medication to make sure no allergic reactions are happening or similar situations have not occurred. In this situation, the nurse moves onto her next task and nothing states she came back to reassess the patient.

When giving oral medications, that are liquid and in a syringe, how would you administer it? A.Place the syringe on top of the tongue and give to the patient slowly, while in a reverse-trendelenburg position B. Place the syringe between the gum and cheek and give the liquid to the patient slowly C. Have the patient sit in bed at a 45 degree angle. Place the syringe between the gum and cheek, and administer it fast D.Connect a 5/8ths needle to the syringe, and administer under the tongue

Answer: B Rationale: When giving an oral medications in a liquid form to a patient that finds it difficult to take medication from a cup, then use a syringe. The syringe should have no needle and should be put between the patients gum and cheek. You should administer the the medication slowly while the patient is in an upright position to prevent aspiration.

Content: Seizures and seizure precautions A newly graduated nurse is providing care to a patient admitted for a recent head injury. As the nurse is making her hourly rounds, she witnesses her patient have a seizure. What is the PRIORITY nursing intervention that the nurse should take? A. Immediately leave the room to seek help. B. Maintain patent airways through oxygen and suction devices. C. Attempt to reorient the client during the event. D. Document the occurrence of a seizure.

Answer: B Rationale: While the client should be reoriented after the seizure subsides and the seizure should be documented, this is not the priority action by the nurse. The nurse should maintain patent airways and provide suctioning to prevent pulmonary aspiration and hypoxia. The nurse should never leave the client unattended and should call for help while remaining in the room.

Content: Skill 9-10: Assisting a Patient with Ambulation Using a Cane While assisting a client ambulate with a cane, the nurse stands slightly behind the client. What is the most correct instruction the nurse should give the client to safely advance forward? a. "Hold the cane on your weaker side to help distribute the weight evenly" b. "Advance the cane 4-12 inches and then, while supporting your weight on the stronger leg and the cane, advance the weaker foot forward" c. "Advance the cane 4-12 inches and then, while supporting your weight on the weaker leg and the cane, advance the stronger foot forward" d. "If you need less support from the cane, you can advance the cane and the stronger leg forward simultaneously"

Answer: B Rational: Holding the cane on the stronger side helps to distribute the client's weight away from the involved side and prevents leaning. The cane should be advanced 4-12 inches (10-12 centimeters) to provide support and balance. When less support is required from the cane, the client can advance the cane and weaker leg forward simultaneously, while the stronger leg supports the client's weight.

Content: Oral Hygiene When accessing a dependent client with oral care which is the least appropriate way to prop the client's mouth open? A. Toothbrush B. Finger C. Mouth Prop D. All the above

Answer: B Rational: Use of a finger to prop open the mouth can lead to accidental bites.

A nurse is providing oral care for a patient with bilateral injuries to the upper extremities. What would be an appropriate toothbrush to use when providing oral care for a patient? A. A large-headed toothbrush with soft bristles B. A small-headed toothbrush with soft bristles C. A large-headed toothbrush with stiff bristles D. A small-headed toothbrush with stiff bristles

Answer: B Rationale: A small-headed toothbrush with soft bristles should be used to reduce the likelihood of breakdown along the gum line due to the head of the toothbrush being overly large or due to irritation from stiffer bristles.

A client is suspected to have blood in their stool after a series of dark stools. A occult blood test is ordered. The nurse collects the sample and puts it on the test paper. After adding the development solution it turns blue. What does this indicate? A. There is no presence of occult blood in the stool. B. There is a presence of occult blood in the stool. C. This indicates the patient has colon cancer. D. This indicates a lower GI bleed.

Answer: B Rationale: After the developing solution is added to the test paper if it turns blue this indicates a positive result. While a positive result could indicate colon cancer further testing needs to be done. It could also indicate a lower GI bleed but usually that blood is bright red.

Content: Monitoring an IV Site and Infusion. While assessing the IV site of a client who has had abdominal surgery, the nurse suspects infiltration. Which finding will support the nurse's suspicions? A) Redness B) Edema C) Pallor D) Heat

Answer: B Rationale: Catheter may become dislodged from the vein, and IV solution may flow into the subcutaneous tissue.

Content: Oral hygiene A nurse is educating a client about how to properly store their dentures. Which of the following is the most appropriate way? A. In a napkin B. In tepid (cold) water C. On the table D. In the sheet

Answer: B Rationale: Cold water helps the dentures maintain their shape. The dentures could be thrown away accidently if placed in a napkin. Lost or broken if left in the sheets. On the table will dry them out and warp them.

Question: For a patient who has just had abdominal surgery and has an incision, what would be the most concerning complication during incentive spirometry use? a. Infection b. Dehiscence c. Dizziness d. Pain

Answer: B Rationale: Dehiscence is when a wound separates and this is a complication that can be caused by incentive spirometry. Splinting the site, placing a pillow or folded blanket over the incision, can prevent dehiscence or evisceration. Splinting the incision will also reduce pain to the site during incentive spirometry. Dizziness and pain are also something we should be cognizant of. If patient complains of dizziness, stop use and tell patient to take some deep breaths. Pain medications should also be given before incentive spirometry use.

A patient has been exhibiting apprehensive behaviors that may lead the patient to needing restraints. The nurse wants to try anything else before deciding to use a restraint. Which of the following could the nurse do to help prevent usage of the restraints? a. Use harsh words and yelling towards the patient because they will not stop with their behavior. b. Make the patient's environment as homelike as possible, providing them with familiar objects. c. Turn out all lights so the darkness will cause them to sleep. d. Allow the patient to sit alone with no visitors.

Answer: B Rationale: Familiarity provides reassurance and comfort, decreasing apprehension and reducing behaviors associated with increased risk for the use of restraints and adequate lighting should be used. When speaking, you should use a calm voice, and its best to not leave a patient alone, it would be even better to have someone (family member or friend) sit with them.

Content: Assisting a Patient with Ambulation Using a Walker Before assisting the patient with ambulation using a walker, have the patient sit on the edge of the bed to assess for _____? A. Pain B. Dizziness or lightheadedness C. Nausea or vomiting D. Blood sugar levels

Answer: B Rationale: Having the patient sit on the side of the bed minimizes the risk for blood pressure changes (orthostatic hypotension) that can occur with position change.

Content: Changing a Wound Dressing A nurse is preparing a patient for a dressing change. What can the nurse do to provide the utmost comfort for the patient? A. Have the visitors in the room observe and comfort the patient during the dressing change. B. Administer a prescribed analgesic 30 to 45 minutes prior to the dressing change and provide complete privacy. C. Massage the area with a hot compress. D. Hand hygiene doesn't have to take place since non-sterile gloves will be used upon the changing.

Answer: B Rationale: If wound care is uncomfortable for the patient, a prescribed analgesic can be administered 30 to 45 minutes prior to the dressing change. Providing privacy by closing the room door and curtain. This puts the patient more at ease and in a more comfortable setting. Also, expose only the area necessary to preform the wound care by proper draping.

Content: Assisting Patient with Oral Care A nurse is providing oral care to a patient. Which step would be most important in regards to patient safety? a. Ensure call light is within reach b. Assist the patient to the side of the bed or turn them on their side c. Prop patient up with pillows d. Raise the bed to a comfortable working height

Answer: B Rationale: It is important to ensure that the patient is in the right positioning to reduce the risk of aspiration. This answer choice gives the most consideration to the safety of the patient.

Content: Applying an Extremity Restraint A client has repeatedly tried to pull out his nasogastric tube. The provider has written an order to apply extremity restraints to make sure the client refrains from pulling out his NG tube. What type of restraint should the nurse apply? Wrist restraint Mitts Sleeve Elbow immobilizer

Answer: B Rationale: Mitts are the least restrictive restraint that would keep the client from pulling out his NG tube. A sleeve would be appropriate if the client was trying to pull on his IV but doesn't keep the client from pulling out his NG tube. Wrist restraints could be used indicated in this situation if the mitts don't work. An elbow immobilizer is appropriate for a client trying to pull at their IV.

Content: Fall Prevention (Safety) Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls? A. Clears a path from bed to bathroom B. Provides slippers for ambulation C. Placing the bed at the lowest setting D. Having the client sit in bed before standing

Answer: B Rationale: Older adults often wear slippers to accommodate swollen feet. Although slippers are more comfortable, they do not offer much support or traction. The unlicensed Assistive Personal should provide the patient with no-skid socks instead. Nonskid footwear prevents slipping and walking shoes improve balance when ambulating or transferring.

A nurse is administering oral medication to a patient, which position in the bed should the nurse assist the patient to receive their medication? A. Semi-Fowlers position B. Upright or lateral (side-lying) position C. Prone position D. Trendelenburg position

Answer: B Rationale: Swallowing is facilitated by proper positioning. An upright or side-lying position protects the patient from aspiration.

Content: Using a Pulse Oximeter/ Monitoring Oxygen Saturation A nurse is preparing to asses pulse oximetry on a client. Upon checking the proximal pulse and capillary refill for adequate circulation for the site, the nurse finds that the site is inadequate. What are the nurses next actions? A. Do not worry about assessing for pulse oximetry. B. Consider and asses alternate sites such as the big toe, earlobe, forehead, or bridge of the nose. C. Inform the provider. D. Use the inadequate site anyway because it is possible to still receive an accurate reading.

Answer: B Rationale: The earlobe, forehead, and bridge of the nose are alternate sites because they are highly vascular and therefore can provide an accurate reading. The big toe may also be used only if the lower extremity circulation is not compromised. Pulse oximetry is very important to asses and should not be excluded. Informing the provider is not necessary in this situation. Using an inadequate site will not provide an accurate pulse oximetry reading.

Content: Administering Medications via a Gastric TubeWhen preparing pills for administration through a gastric tube you should: A: Crush each pill, one at a time, and put them all into the same medication cup to dissolve together B: Crush each pill, one at a time, and put into separate medication cups and dissolve with 15-30mL of water C: Crush all the pills at the same time and pour the powder into the tubing first, then flush with 30mL of water D: Crush each pill, one at a time, and put into separate medication cups and dissolve with 15-30mL of sterile saline

Answer: B Rationale: The medications may not by physically or chemically compatible; mixing them can lead to tube obstruction or altered therapeutic actions.

Content: Testing Stool for Occult Blood A nurse just collected the stool sample from the patient and applied to to the FOBT card. What is the shortest amount of time the nurse should wait before adding the developer to sample? A. 1-3 minutes B. 3-5 minutes C. 6-8 minutes D. 8-10 minutes

Answer: B Rationale: The nurse should wait 3-5 minutes to put the developer on the sample to ensure an adequate amount of time for the sample to adhere to the test paper and dry. Any time shorter than that would not give the sample enough time to dry.

Content: Assisting with Ambulation using a cane A nurse is educating a nursing student on how to assist a client who ambulates with a cane. Which action from the nursing student indicates further teaching is required? A. The nursing student puts slip resistant socks and a gait belt on the ambulating patient. B. The nursing student plans the length and duration of the walk before entering the clients room. C. The nursing student stands along the weak side of the body, slightly behind while the patient is ambulating. D. The nursing student instructs the client to hold the cane opposite their weaker/ injured side for support.

Answer: B Rationale: The nursing student should not decide the length and duration on their own. They should consult with the patient and take into consideration their physical abilities. The nursing student should put slip resistant socks and a gait belt on the patient. They should also instruct the patient to hold the cane opposite their weak side. The nursing student should remain slightly behind the patient on the weaker side.

QUESTION 1 Content: Applying an Extremity Restraint A client in the hospital requires extremity restraints that have been ordered by the physician. The patient's chart indicates that the doctor has not physically come to assess the patient yet after writing the order an hour ago. What is the nurses PRIORITY action? a. Go ahead and put the restraints on the patient b. Contact the provider immediately to come assess the patient c. Document you are waiting for the provider to assess the patient d. Explain to the patient and family member why the restraints are being used

Answer: B Rationale: The provider must physically see the patient and assess the need for restraints within an hour before ordering restraints. The nurse would need to contact the provider to come see the patient and then could document the need for restraints and apply the restraints.

You are performing irrigation of a client's pressure injury. Which of the following steps is NOT appropriate? A. Put on a gown, mask, and eye protection/face shield. B. Keep the tip of the syringe at least half an inch above the upper edge of the wound. C. Discontinue irrigation when the solution flowing from the wound is clear. D. After securing the dressing, label it with the date and time.

Answer: B Rationale: The tip of the syringe should be kept at least one inch above the upper edge of the wound. All other answers describe appropriate steps.

Content: Employing Seizure Precautions and Seizure Management 2. In regards to the patients privacy, what is one thing a nurse can do for a client having a stroke? A. Close the patient's eyes. Speak in a calming voice. B. If possible, close the curtains around the bed or the door to the room. C. Apply padding to the side rails. D. Cover the client with their blanket.

Answer: B Rationale: This ensures the patient's privacy.

A newly licensed nurse is applying an extremity restraint. which action by the nurse requires further teaching? A) Uses a quick-release knot to tie the restraint to the bed frame, not side rail. B) Ensures that one finger can be inserted between the restraint and patient's extremity C) Removes the restraint at least every 2 hours, or according to facility policy and patient need. D) Makes sure the call bell is within the patient's reach.

Answer: B Rationale: Two fingers should be inserted between the restraint and patient's extremity. Proper application ensures that nothing interferes with the patient's circulation and potential alteration in the neurovascular status.

Content: Administering Oral Medications A nurse has gathered all of the correct medications for her patient and has given them to the patient in a cup. The prescriber has not indicated that the medication is able to be left on the bedside. What would the nurse do next? a. Return back to the computer to document b. Watch the patient take the medication c. Leave the patients room in order to document d. Tell the patient he/she will be back to check on them in 30 minutes

Answer: B Rationale: Unless you have seen the patient take the medication, you cannot document the medication as administered. The medication can only be left at the beside if the prescriber has said it is okay.

Content: Administering Oral Medications A 55 year old female patient is refusing antibiotics because she states that she hates swallowing pills. What technique should the nurse use in order to properly administer the medication? a. Administer medication anyway b. Provide education towards the medication and the risks for refusing the medicationc. Notify the nurse manager so they can speak with the patient d. Tell the patient if she refuses the medication she will be removed from the hospital

Answer: B Rationale: Why delegate when you can EAT. The nurse should educate the patient about the medicine while sharing the importance of it and advise her towards the risks for not taking the medication. Administering the medication without the patient's consent is battery. The nurse manager should be informed of the incident but ultimately the nurse should be able to speak with the client first. Threatening the patient for not taking the medication is assault.

Question 1: A nurse is educating a patient on ambulation using a walker who has an unsteady gait. How far should you educate the patient to move the walker with each step? A. 12-18 inches B. 6-8 inches C. 2-4 inches D. have the patient step forward before moving the walker

Answer: B Rationale: You should instruct the patient to only move the walker forward 6-8 inches before stepping as that is the length of a typical step for someone with an unsteady gait and this length keeps the patient's center of gravity.

Content: Testing stool for occult blood A nurse is preparing a stool test for a patient who suspected blood in the stool. A 32 years old patient recently diagnosed with ulcer disease and completing a severe pain (7 of 10 on pain scale). A nurse is planning to give a pain medication that relieve patient's pain before process stool test for occult blood. Is the nurse action being appropriate? Yes, the nurse action is appropriate, pain medication administered before process stool test to relief patient's pain. No, the nurse action is not appropriate, pain medication administered before process stool test to relief patient's pain.

Answer: B Rationale: the nurse should administer pain medication after stool testing and after get the specimen from the patient. Administered pain medication before stool testing can lead to false positive result, which cannot diagnose specific pathogen or disease that currently patient had.

Three Checks and The Rights of Medication Administration A nurse is preparing to administer medication to a patient. When should the third check of medication administration be performed? Select all that apply A.) When she pulls the correct medication from the drawer B.) When she rechecks the medication label with the eMAR at the patient's bedside C.) When she holds the correct medication to compare to the eMAR D.) While she is preparing the medication E.) When she checks all the prepared medication labels with the eMAR before taking them to the patient

Answer: B & E Rationale: The third check can be done one of two ways, depending on facility policy. It can be performed when you recheck the labels with the eMAR at the patient's bedside, or when you recheck the labels of all the patients prepared medication to the eMAR before going into the patients room for administration.

Question involving use of canes: Your patient is getting ready to ambulate. The patient has bilateral weakness. Which ambulatory device should the patient use? Select all that apply. A.) Cane B.) Walker C.) Crutches D.) Wheelchair

Answer: B and C. Patient should not use cane if they have bilateral weakness. Wheelchair is not a valid option since the patient can ambulate but just needs more assistance.

Content: Teaching Patient to Use an Incentive Spirometer (Skill 14:2, Module 4)Which of the following are the correct techniques when using an incentive spirometer? (Select all that apply) A: Patient will exhale slow and as long as possible B: Patient will hold there breathe for 3 seconds afterwards C: Patient should use the spirometer 5 - 10 times every 1 to 2 hours D: Patient will inhale slow and as deeply as possible E: Patient should use the spirometer 10 - 20 times every 3 to 4 hours

Answer: B, C, D Rationale: The incentive spirometer indicates inhalation volume and measurement of lung expansion and holding the breath for 3 seconds after inhalation allows the alveoli time to re-expand. This procedure helps inflate the alveoli to prevent atelectasis from hypoventilation and reach normal lung volume.

Question of Fecal Occult Blood Sampling: When screening for colon cancer, how many stool samples should you obtain consecutively? A.) 4 consecutive stool samples B.) 3 consecutive stool samples C.) 1 stool sample D.) 2 consecutive stool samples

Answer: B. When doing a fecal occult blood sample test, you should obtain 3 consecutive stool samples.

Content: Implementing Alternatives to the Use of Restraints A confused older patient keeps getting out of his bed. The nurse should consider which of the following first before considering a restraint? (Select all that apply) A. Place patient in a room closer to the nursing station. B. Raise all four rails of the clients bed. C. Asking a family member to stay with the client D. Administer a sedative to calm the patient.

Answer: Both A&C: Rationale: These choices are most appropriate options to consider before applying a restraint. The other two are types of restraints and should not be the first option. Restraint use in older adults is associated with falls and injurious falls, pressure injuries, and other adverse outcomes. The expected outcome to achieve when implementing alternatives to restraints is that the use of restraints is avoided, and the patient and others remain free from injury. Alternatives to restraints and less-restrictive interventions must have been implemented and failed. All alternatives used must be documented.

The nurse is changing the dressing on a patient's surgical wound. After the old dressing is removed, the nurse notices that the patient's skin is red and blistered where the dressing had been secured with tape. Which of the following would be an appropriate action by the nurse? Allow the wound to air dry Replace the dressing with smaller ones Replace the dressing with larger ones Notify the health care provider for further instructions

Answer: C Rationale: The nurse would place a new larger dressing on the wound area in order to prevent further aggravation by the tape.

Q2: Content: Skill 9-10: Assisting a Patient with Ambulation Using a Cane While assisting a client ambulate in the hallway, they suddenly say "I can not walk anymore!" What should you do first? a. Lower the client to the floor b. Assess the client for possible causes c. Call for help d. Notify the provider

Answer: C Rational: Call for assistance. Have a coworker obtain a wheelchair to transport the client back to her room. Assess the client for possible causes, such as anxiety, fatigue, or a change in condition. In the future, plan shorter distances to prevent the client from becoming fatigued. Contact the provider for a referral for physical therapy for muscle strengthening.

Content: Collecting a Stool Specimen A nurse is collecting a stool specimen for a client. Which of the following is the most appropriate action for the nurse to take? A. Make sure the patient voids after collecting the stool sample. B. After placing stool into appropriate container, place the container into any bag that is available and send to lab. C. Make sure to collect sample before antibiotics are administered. D. Retrieve stool from the toilet directly.

Answer: C Rationale: Administering antibiotics before stool sample is collect can cause the stool to have decrease amount of bacteria and cause inaccurate lab results. The patient needs to void before the specimen is collected to urine is not in the sample. After collecting the sample, it should be placed in a biohazard bag. A nurse does not retrieve stool from a toilet for specimen use.

Content: AIDET and Hourly Rounding The nurse would do all of the following during AIDET and hourly rounding EXCEPT? a. managed up self and others b. give time expectation of how long test, procedure, etc. will take c. explain once at the very beginning of procedure what is going to happen d. use language the patient and family would understand\

Answer: C Rationale: A part of the Duration section of AIDET is to verbalize each step before doing it, to let the patient and family know what is going to be done.

You are caring for a patient who is fully continent of bladder, but has just fallen while trying to go to the bathroom. What is an alternative method the nurse can apply before the use of restraints? A. Ensure all four side rails are up when you leave patients room. B. Bed in highest position, so patient cannot get down. C. Ensure patient's assistive devices are within reach. D. Insert a Foley catheter on patient.

Answer: C Rationale: All four side rails up on patients bed is a form of a restraint. Having the patients bed at the highest portion is just very unsafe. Inserting a Foley catheter is an extreme measure after only one fall and also the patient is fully continent of bladder. Ensure patient's assistive devices are within reach will allow the patient to safely ambulate to and from the bathroom and therefore is the best answer.

Content: Urinary Catheter Care When placing an indwelling urinary catheter, where should the nurse hold the catheter? A. 4 to 5 in (10 to 12.5 cm) from the tip of the catheter B. At the tip of the catheter C. 2 to 3 in (5 to 7.5 cm) from the tip of the catheter D. 1 in (2.5 cm) from the tip of the catheter

Answer: C Rationale: By holding the catheter 2 to 3 in from the tip, it allows for adequate control while decreasing risk of contamination. Also, advancing an indwelling catheter an additional 2 to 3 in (4.8 to 7.2 cm) ensures placement in the bladder and facilitates inflation of the balloon without damaging the urethra.

A student nurse is cleaning an abdominal wound on a client. Which of the following actions made by the student nurse would require a Registered Nurse to intervene? A. The student nurse uses a new gauze for each wipe. B. The student nurse sprays the wound from top to bottom with a commercially prepared wound cleanser. C. The student nurse wipes the wound from bottom to top and outside to inside. D. The student nurse uses sterile technique.

Answer: C Rationale: Cleaning from top to bottom and center to outside ensures that the wound is cleaned from the least to most contaminated area and that a previously cleaned area is not contaminated again. All of the other answer choices are proper wound cleaning skills.

Content: Adminestering Oral Medications A nurse is preparing a medication for one of her patients from a multidose container. The patient is prescribed one capsule of Tylenol as needed for his fever. How should the nurse retrieve this medicine from the multidose bottle? a. Bring the multidose bottle into the patient's room and pour the correct amount into the patient's hands. b. Pour the correct amount into the bottle cap but If too many come out pick them up and place them back into the bottle. c. Pour the correct amount into the bottle cap, then pour it into a medicine cup. d. Pour the correct amount into your hand, then transfer it into a medicine cup.

Answer: C Rationale: Do not pour the medication directly into the patient's hand as this is unsanitary and you may poor too many. Touching the medication with your fingers is unsanitary so if too many come out, pour them back into the bottle from the bottle cap. Pouring the medicine into the bottle cap allows you to ensure the correct amount comes out and is the most sanitary way. Pouring the medication into your hands is unsanitary and not the correct answer choice.

A nurse is assessing a pressure injury and sees that it has full thickness loss, adipose tissue visible, and slough on the sacrum area. What stage pressure injury would the nurse chart in the patients medical record? Stage 1 pressure injury Stage 2 pressure injury Stage 3 pressure injury Stage 4 pressure injury Unstageable pressure injury

Answer: C Rationale: Full thickness loss indicates that the pressure injury is either a stage 3 or 4. Since the nurse does not see any muscle, tendons, ligaments, cartilage or bones it indicates that it is not a stage 4 pressure injury. The nurse sees only adipose tissue rather than muscle, tendon, ligaments etc. which indicates it is a stage 3 pressure injury.

A client presents with a stage two pressure ulcer ( shallow, partial skin thickness with no necrotic areas). The nurse would treat the area with which dressing? a. Wet gauze b. Dry gauze c. Hydrocolloid d. No dressing indicated

Answer: C Rationale: Hydrocolloid dressings provide a moist and insulating healing environment which protects uninfected wounds while allowing the body's own enzymes to help heal wounds. Hydrocolloid protects shallow ulcers while maintaining an healthy healing environment.

Content: Using Personal Protective Equipment A nurse is about to doff her PPE equipment. If the nurse tied the gown at the front of her body, at which step would she untie it? A. After removing the gloves B. After removing the mask C. Before removing the gloves D. Before removing the goggles

Answer: C Rationale: If the nurse tied the ties of the gown at the front of the body, then they need to be untied before removing the gloves. This is because the front of the gown is considered contaminated, so you would not want ungloved hands touching a contaminated area.

Content: Wound IrrigationWhen performing wound irrigation, the irrigation solution should flow from: A: From the bottom of the wound to the top of the wound B: From the left side of the wound to the right side of the wound C: From the top of the wound to the bottom of the wound D: It does not matter as long as you clean the entire wound site

Answer: C Rationale: Irrigating from top to bottom, will allow gravity to direct the flow of liquid from the least contaminated to the most contaminated area.

Content: Teaching a patient to use an incentive spirometer A nurse is doing education on incentive spirometer use. Which would be the most appropriate amount to use the incentive spirometer? a. 2 times every 3-4 hours b. 6-8 times every 1-2 hours c. 5-10 times every 1-2 hours d. 4 times every 2-3 hours

Answer: C Rationale: Optimal use of the incentive spirometer is 5-10 times every 1-2 hours while awake.

Content: Seizure Precautions and Management Which of the following is NOT an appropriate technique in seizure management? A) Place the patient on side with head flexed forward. B) Clear airway using suction as appropriate. C) Restrain the patient. D) Loosen constrictive clothing.

Answer: C Rationale: Restraining the patient can cause injury. On the side with head flexed allows the tongue to fall forward, minimizing risk of aspiration. Suctioning the airway is sometimes necessary for adequate ventilation. Constrictive clothing can cause injury

A new nurse is caring for a patient with a history of seizures. In the event of a seizure, which response by the new nurse would indicate that further education is required? a. "If the patient is seated, I will ease the to the floor to prevent falling." b. "I will loosen tight clothing to prevent injury." c. "I will restrain the patient to prevent the patient from falling from the bed." d. "I will time the length of the seizure."

Answer: C Rationale: Restraints can cause injury to the patient. Instead, the nurse should guide the patients movements to help prevent injury.

Content: Applying and Removing Graduated Compression Stockings A nurse is proving care to a patient who is wearing graduated compression stockings on both legs. While assessing the patient's extremities, the nurse notices his feet are blue, cold, and are swollen. What should the nurse do? A Loosen the compression stockings. B Do nothing because this is a normal finding. C Remove the stockings and notify the provider. D Allow the patient to ambulate to get the blood circulating to his feet.

Answer: C Rationale: You are not able to loosen compression stockings, as they are fitted to the patient's leg. Blue, cold, and swollen extremities are not a normal finding on someone who is wearing compression stockings. Blue, cold, and swollen extremities could put the patient in danger if they tried to ambulate.

Which statement made by a student nurse about restraints best demonstrates to a nursing instructor that teaching has been successful? A: "I will untie the extremity restraints from the side rail every two hours to allow the patient to perform range-of-motion exercises." B: "After 48 hours, the physician or other licensed independent practitioner must see and assess the patient before writing a new order for restraints if the patient is 18 years of age or older." C: "I must assess the patient's skin integrity at least every one hour." D: "After 12 hours, the physician or other licensed independent practitioner must see and assess the patient before writing a new order for restraints if the patient is under nine years of age."

Answer: C Rationale: Restraints should not be tied to the side rails. After 24 hours, the physician or other licensed independent practitioner must see and assess the patient before writing a new order for restraints to manage violent or self-destructive behavior if the patient is 18 years of age or older. The physician or independent practitioner must assess a patient who is under nine years old after 24 hours before writing a new order for restraints to manage violent or self-destructive behavior. The nurse must perform an assessment every hour that includes skin integrity according to Step 16 on p. 161

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document? A. Sanguineous B. Serous C. Serosanguineous D. Purulent

Answer: C Rationale: Serosanguineous contains both blood and a clear yellow liquid. It is common to see this kind of drainage from a fresh cut but there are other substances that may also drain from a wound.

A student nurse notices the experienced nurse has not checked back on the patient who had their wound cleaned 3 hours ago. Why might this be a problem? a. The patient could be boredb. The patient may be at risk for fallingc. The patient could be at risk for a pressure ulcer due to lack of mobility d. The nurse could lose her job for lack of work ethic

Answer: C Rationale: The most important situation in this case is that every patient should be re-positioned every 2 hours not only because they have a wound but because it relieves the amount of pressure the patient puts on their skin and to prevent more pressure ulcers. The patient being bored is not the main concern. The patient could be at risk for falling due the nurse not checking up on him. The nurse losing her job is not the priority of this situation, the patient is the main concern.

You have completed the education on ambulating with a walker with the patient. Which statement by the patient proves that the needs further teaching? A. I should wear shoes or non skid socks to prevent falling B. I should sit on the edge of the bed or the chair before getting up with the walker to ensure that I am steady and not dizzy C. I can use the walker to pull myself up from the chair or bed D. I should not use my walker when I am taking stairs

Answer: C Rationale: The patient should use the arms of the chair or a assistant device for leverage when getting up; the patient should not use the walker to pull themselves up, as the walker could tip over or become unbalanced and the patient could fall.

After a nurse removes a soiled dressing from a patient's wound, what should the nurse do next? A. Remove soiled gloves and dispose of them in an appropriate waste receptacle. B. The nurse should irrigate the wound. C. The nurse should note the presence of drainage from the wound. D. The nurse should measure the width, length, and depth of the wound.

Answer: C Rationale: The presence of drainage should be documented.

Content: Three Checks and "rights of administration The new nurse is aware that there are three checks when administering medication through a needle. At which point should the nurse do the final check? A. As the nurse pulls up the medication B. After administering the medication C. At the bedside, after drawing the medication D. Before she enters the room to administer

Answer: C Rationale: The third and final check is at the bedside, and the patient should be identified and checked against the medication, or per facility policy. The other three choices are too early in the process before medication administration.

A nurse is preparing to give afternoon medications to one of her patients. After she reads the MAR/eMAR and gathers the right medications from the drawer and compares the medications to the MAR/eMAR what is the nurses next step? Give the medications to the patient Ask a coworker to check the medications Check the medication labels with the MAR/eMAR Prepare the other patients medications so that she will not have to re-enter the medication room

Answer: C Rationale: The third check of medication administration is to check the labels of the medications with the MAR/eMAR to ensure that you have the right medications before administering them to the patient.

Content: Seizure Precautions A nurse is assisting a patient during a seizure. Which of the following rules would the nurse use during this incident? a. Stick your hand into the patients mouth to grab tongue b. Make sure patient is wearing tight clothing c. Have two to three side rails up and padded on bed d. Bed is in highest position

Answer: C Rationale: This keeps patient from falling out of bed and into a worse condition. You should not stick objects into a patients mouth while seizing. Furthermore, make sure patient is wearing loose clothes and the bed is in the lowest position.

When applying an external heating pad, which prescription from the health care provider would the nurse question? A. Maintain the temperature between 105 degrees F to 109 degrees F B. Use gauze to secure the heating pad to the site of application. C. Leave heating pad on for 40-45 minutes, then off for two hours. D. Assess site frequently during application of the heating pad.

Answer: C Rationale: Using heat for more than 30 minutes results in tissue congestion and vasoconstriction, known as the rebound phenomenon. Prolonged heat application may also result in tissue damage or burns.

Skill 8-1: Cleaning a Wound and Applying a Dry, Sterile Dressing The nurse is removing old dressings before cleaning a client's wound. The gauze from the dressing is stuck on part of the wound. Which of the following is the correct way to remove the stuck dressing? A. Keep pulling until the dressing comes loose. B.Use small amounts of tap water to help loosen and remove the gauze. C. Use small amounts of sterile saline to help loosen and remove the gauze. D. Wait a few days for the dressing to come loose by itself.

Answer: C Rationale: Using sterile saline is the correct technique when trying to remove gauze that is stuck to a wound, as this reduces damage and pain. Trying to keep pulling the dressing will cause the patient pain and could damage the wound further. Using tap water is not appropriate because it could increase the risk of infection. Leaving the old dressing on can also increase the risk of infection and delay healing.

Your patient is due for a dressing change. Upon removal of the old bandage you inspect the wound and notice that there is tunneling present. What would you use to measure the depth and direction of the wound? A.) Ruler B.) Sterile tongue depressor C.) Sterile cotton-tip applicator D.) A visual estimate

Answer: C Rationale: You would want to use a sterile cotton-tip applicator that has been moistened with saline to measure the depth and the deepest sites of the wounds tunneling.

Content: Ambulation using a Cane A nurse is providing an ambulation with elderly patient who are poor balance of body posture and weakness which can increased high risk of falling. The nurse needs to assist the patient to walk with cane. Which equipment is not appropriate to use while ambulation a patient using a cane? Cane of appropriate size with rubber tip Nonsterile glove and/or other PPE, as needed Skid shoes or slippers Gait belt and/or other supplement, as needed

Answer: C Rationale: the nurse should be applying non-skid shoes or slipper on the patient before ambulate a patient using a cane. Skid shoes and slippers are leading the patient into high risk of falling and it is not safety consideration of patient

Content: Patient Identification A nurse is about to perform a procedure on a client. List in order the proper steps in which the nurse should perform when correctly identifying the client. A. Discuss and explain the procedure to the client B. Continue with client care as appropriate C. Identify the client using two identifiers

Answer: C A B Rationale: First, correctly identify the client. This validates the correct client and the correct procedure. Second, discussing and explaining the procedure to the client helps alleviate anxiety and helps prepare the client for what to expect. Lastly, continue with the appropriate care specified for the client. You would not explain the procedure or provide client care without identifying the client first. Continuing with client care before discussing and explaining the procedure may cause the client to have anxiety and uncertainty about what to expect.

Content: Collecting a Stool Specimen for Culture A nurse is collecting a stool specimen for culture. The nurse should collect as much of the stool as possible into _____________. A. a sterile container. B. a biohazard bag. C. a clean specimen container.

Answer: C. The container does not have to be sterile, because stool is not sterile. So the sterile container would be most appropriate.

Content: Venipuncture When performing venipuncture on a client for routine testing, which of the following actions by the nurse indicates the need for further teaching? A. Placing the vacutainer and needle in the sharps container once all labs are drawn. B. Leaving the tourniquet in place for no longer than 60 seconds. C. Applying pressure and traction to the skin 1-2 inches below the injection site. D. Disposing of the needle without engaging the safety.

Answer: D Rationale: The guard on the needle should be engaged immediately after removal from the patient. Traction should be held below the venipuncture site, the tourniquet should not be kept on for longer than 60 seconds, and the vacutainer and needle should be discarded in the sharps container.

A nurse is performing a situational assessment. The nurse notes the presence of children and cleaning products, without a lid, being within reach. What would be the nurses next action? a) Nothing b) Place the lid on the cleaning products, move along c) Throw away the cleaning products d) Provide education regarding safe storage

Answer: D If there are children in the home, evaluate the method used to store medications, cleaning products, insecticides, and corrosives. Provide education regarding safe storage as appropriate.

Content: Assessing a Wound While performing an assessment the nurse observes a stage III pressure ulcer on the patient. How would the nurse document the appearance of the wound? a. Intact skin with non-blanchable redness of a localized area b. full-thickness tissue loss with exposed bone c. partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough d. full-thickness tissue loss. No bone, tendon or muscle is exposed

Answer: D Rationale: A stage III pressure ulcer is defined as full-thickness loss of skin, where adipose is visible, slough may be present, but there is no bone or muscle exposed.

Content: Compression Stockings What of the following is NOT a consideration that would be used in application of compression stockings? a. apply stockings in the morning before the patient is out of bed and while the patient is supine b. if patient is sitting or has been up, have patient lie down with legs and feet elevated for at least 15 minutes before applying stockings c. assess condition and neurovascular status of legs d. measure one leg and provide a pair of stockings accurate to measurements

Answer: D Rationale: Both legs are required to be measured to obtain the correct stocking size for each leg, as the patient may have measurements that differ.

Content: Obtaining a Urine Specimen from an Indwelling Urinary Catheter When obtaining a urine specimen from an indwelling urinary catheter, the nurse should perform which step before attaching the syringe to the needleless port? A. Place label on specimen container B. Unclamp the catheter drainage tubing C. Don sterile gloves D. Scrub aspiration port vigorously with alcohol or other disinfectant wipe and allow port to air dry

Answer: D Rationale: Cleaning with alcohol or other antimicrobial wipes prevent entry of microorganisms when the needle punctures the port.

While cleaning the teeth of your client, you notice that the gum is starting to bleed. What would be the most appropriate action? A. Allow the patient to rinse with water and keep brushing B. Change to another toothbrush C. Apply numbing gel on the gums for the pain D. Stop brushing, let the patient gently rinse with water and check most recent platelet level before continuing

Answer: D Rationale: If your client's gums are bleeding you should always stop brushing because you don't want to cause further irritation. Check the most recent platelet level to make sure it's in normal range and if it is then possibly consider changing to a softer toothbrush.

A nurse is taking care of a patient with an IV site, what signs and symptoms should the nurse look for if infiltration was to occurs. a. headaches and swelling b. redness and heat c. bleeding at the site d. swelling, pallor, coolness, pain around the infusion site

Answer: D Rationale: Infiltration : the escape of fluid into the subcutaneous tissue. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site; significant decrease in the flow rate.

You are administering medication to an adult client via the patient's nasogastric tube. Which of these actions is appropriate for this procedure? A. Flush the tube with 30 to 60 mL water before and immediately after giving the medication. B. Mix medications that have been ground into powder with 5 to 10 mL of water before administration. C. Give cold medication before it reaches room temperature. D. Remove the clamp from the tube and check tube placement before administering the drug.

Answer: D Rationale: It is important to check tube placement in order to prevent aspiration. The tube should be flushed with 15 to 30 mL of water before and immediately after giving the medication. Ground medications should be mixed with 15 to 30 mL of water. Cold medication should be brought to room temperature before administration.

A 93-year-old patient in a long-term care facility is suffering from "memory loss" and is charted as a fall risk. Which of the following is the best nursing intervention to prevent fall risk? a.) Place the patient on leg restraints. b.) nurse should check on the patient regularly at night. c.) Provide daily activities to keep the patient active. d.) Place a bed exit alarm on the patient bed.

Answer: D Rationale: The bed exit alarm will work great for this patient because it alerts the nurse immediately if the patient has gotten out of bed. If the patient is suffering from memory loss and falls while out of his/her bed, he/she could be on the floor for a long time with life-threatening injuries and this could be dangerous.

Content: Venipuncture and Order of Draw A student nurse is reviewing the steps of a venipuncture with her clinical instructor. Which of the following statements indicates a need for further education? A) "I will allow the skin to completely dry after I clean it." B) "I will not palpate the site after I have cleaned the area." C) "I will insert the needle at a 15-30 degree angle." D) "I will remove the tourniquet after I have filled all the required tubes."

Answer: D Rationale: The tourniquet should be removed as soon as blood flows adequately into the tube to reduce venous pressure. Allowing the skin to dry maximizes antimicrobial action. Palpating the site after cleaning would contaminate the spot, unless sterile gloves are used. These angles reduce the risk of puncturing through the vein.

The primary care physician for your client has ordered a blood culture to assist him in his diagnosis. After gathering the necessary materials, you head to the patient's room and attempt to draw the blood. You apply the tourniquet and begin looking for a distended vein but cannot find one. What should you do? A Remove the tourniquet and tighten its hold around the arm B Apply a warm compress for about 30 minutes before returning to try again C Have the patient make a fist and pump is multiple times D Remove the tourniquet and try lowering the patient's arm to allow blood to pool in the veins

Answer: D Rationale: Tightening the tourniquet could possibly lead to hemoconcentration or other erroneous results on the test. Warm compresses should only be applied for 10 minutes before reattempting venipuncture. While making the fist is appropriate, having the patient pump their fist may increase plasma potassium levels.

Content: Skin Integrity and Wound Care Wound care and procedures requiring the use of a sterile field and other sterile items are not delegated to? A. BSN Nurses B. Licensed Practical Nurses C. Licensed Vocational Nurses D. Nursing Assistive Personnel

Answer: D Rationale: Wound care and procedures requiring the use of a sterile field and other sterile items are not delegated to nursing assistive personnel (NAP) or unlicensed assistive personnel (UAP). Depending on the state's nurse practice act and the organization's policies and procedures, these procedures may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances, as well as the qualifications of the person to whom the task is being delegated.

Content: Testing for Occult Blood Blue areas on the occult blood card indicates? a. Negative Result b. Infection c. Injury d. Positive Result

Answer: D Rationale: Any blue coloring on the card indicates a positive test result for blood.

The nurse is trying to assist a client with ambulation using a walker. The client is complaining of pain 7/10 for which she has a PRN analgesic order. Which step should the nurse implement first in planning/performing the procedure for this client? A. Review the medical record and nursing care plan for conditions that may influence the patient's ability to move and ambulate. B. Perform hand hygiene upon entering the room. C. Gather the supplies needed for the procedure. D. Perform a pain assessment, administer ordered pain medication and reassess pain after enough time has passed for the analgesic to take effect.

Answer: D, Perform a pain assessment, administer ordered pain medication and reassess pain after enough time has passed for the analgesic to take effect. (answer order: D, A, C, B) Rationale: C and B, The nurse would gather supplies before performing hand hygiene and entering the room. Performing hand hygiene the moment the nurse enters the room, and no sooner, helps prevent the transmission of pathogens. A and C, The nurse would review the medical record and nursing care plan for conditions that may influence the patient's ability to move and ambulate before she would gather supplies. A and D, This question can be tricky but this point must be hammered home. While it is true that the nurse would check the client's record before administering any pain medication in preparation for a procedure, the nurse should ALWAYS review the most up-to-date information available when determining any contraindications before performing any procedure. That means that after the analgesic takes effect the nurse will check the record again and this time considering any contraindications that may have arisen from the administration of the medication as well as anything else that may have changed in the time between the nurse giving the analgesic and the it taking effect.

Content: Skill 14-2: Teaching a Patient to Use and Incentive Spirometer Who can a nurse appropriately delegate the teaching of using an incentive spirometer to a patient to? A. Licensed Practical Nurse (LPN) B. Nursing Assistive Personnel (NAP) C. Unlicensed Assistive Personnel (UAP) D. The nurse should not delegate this task.

Answer: D. Rationale: Patient teaching related to using an incentive spirometer use should not be delegated. Depending on the organization's policies the nurse may be able to delegate reinforcement and encouragement to use the spirometer to an LPN after initial teaching.

Content: AIDET & Hourly Rounding A nurse enters a room acknowledges the client and their partner who are in the room together. He then introduces himself and says he will only need a few minutes. He then begins taking out the supplies and silently drawing blood. He then thanks everyone and leaves the room. Which step of AIDET did he skip? A. Acknowledge B. Introduce C. Duration D. Explanation E. Thanks

Answer: D. Rationale: The nurse acknowledged everyone, introduced himself, and gave the patient a timeframe, he failed to explain the procedure though and then thanked the patient as he left.

Content: Using PPE A nurse entering a patient's room who is under airborne precautions should don which PPE? Select all that apply. A. Gown B. Mask C. Goggles D. Gloves E. N-95 respirator

Answer: E and D Rationale: A N-95 respirator is required when entering this room due to the decreased particle size of airborne illnesses. Gloves are a standard precaution and should always been worn when working directly with a client.

Content: Safety A nurse is caring for an elderly patient at home after having a fall. What safety precautions would the nurse employ to minimize potential risk of fall? a. Removing electrical cords from walkways b. Wearing non skid foot wear c. History of previous falls and limitations d. Educating patient and family on new home precautions e. All of the above

Answer: E. Rationale: Incorporating knowledge of safety factors along with knowledge of mobility limitations to the development of care that minimizes the risk of falls.

Content: Pulse Oximetry A nurse is preparing to take her patients pulse oximetry. Before doing so, the nurse believes she should check the patients hemoglobin. Is she correct? A. True B. False

Answer: TRUE Rationale: It is important to know the patient's hemoglobin level before evaluating oxygen saturation because the test measures the percentage of oxygen carried by the available hemoglobin only. This means that a patient with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the patient may not have enough oxygen to meet the needs of the body.

Question: While brushing a patient's teeth, you notice bleeding along the gum line. What action would be most appropriate? Select all that apply. a. Stop brushing the patient's teeth and do not try again. b. Continue brushing, this is normal. c. Stop brushing, rinse patient's mouth with water and instruct patient to spit into emesis basin. d. Consider using a softer toothbrush.

Answer: The correct answer would be both C and D. Rationale: A bleeding gum line can be due to many different things and we would not want to further any damage by continuing to brush. We should stop brushing and assess the cause of bleeding gums before continuing. Using a softer toothbrush could prevent irritation to the patient's gums. With excessive bleeding, check platelet counts.

A nurse is preparing to collect a urine specimen from a client who has an indwelling urinary catheter. Which of the following actions should the nurse perform prior to obtaining the specimen? A Clean the tubing port with an antiseptic solution. B Provide catheter care. C Elevate the drainage bag above the bladder. D Put on sterile gloves.

Answer: a Rationale: Prior to obtaining the sample, the port should be cleaned with an antiseptic such as alcohol or another disinfectant. A syringe is used to aspirate 3-5 mL of urine from the port.

Content: Collecting Stool Specimens A nurse is collecting a stool specimen from a patient. How much stool is sufficient for a specimen? a. 1 in. of formed stool/ 15- 30 mL of liquid stool b. 1/2 in. of formed stool/ 10- 15mL of liquid stool c. 1 1/2 in. of formed stool/ 30-40 mL of liquid stool d. 2 in. of formed stool/ 15-20 mL of liquid stool

Answer: a Although you want to collect as much stool as possible, 1 in of formed stool or 15-30 mL of liquid stool will be sufficient for testing.

Content: Assisting a Patient with Ambulation Using a Cane A nurse is assisting a patient with ambulation using a four prongs cane or a quad cane. The nurse understands that this type of cane is most effective because the patient is described how? a. In need of assistance related to poor balance. b. Able to ambulate stairs frequently and independently. c. In need of assistance and exhibits hand weakness. d. Requires minimal assistance and maintains proper balance.

Answer: a Rationale: A four prongs cane or a quad cane provides a wider base of support for the client. The wider base allows the cane to be most effective for those with poor balance

Content: Aidet and hourly rounding Which of the following words are not a part of AIDET? a. Inform b. Explanation c. Acknowledge d. Thank you

Answer: a Rationale: AIDET stands for Acknowledge, Introduce, Duration Explanation, and Thank you. The 'I' in AIDET stands for introduce because it is important to introduce yourself to the patient. You give details to the patient about what is going to happen, why, and what they should expect during the explanation portion of AIDET.

Content: Hygiene A nurse is providing foot care to an elderly client who has diabetes and decreased mobility. What technique would the nurse employ when providing foot care? a. Use an antifungal powder on the client's feet if necessary. b. Carefully remove any corns or calluses that are present. c. Soak the client's feet for 15 to 20 minutes in hot water prior to cleansing. d. Avoid using soaps or commercial cleansers whenever possible.

Answer: a Rationale: Antifungal foot powders may be used when indicated, and it is appropriate to use soap and/or cleansers when providing foot care. Corns and calluses should not be removed, and the nurse should avoid soaking the client's feet.

Content: Applying and Removing Graduated Compression Stockings A nurse is providing foot care to a client who needs to change graduated the compression stockings. Which statement shows the nurse needs further education? a. Assess the skin condition and neurovascular status of the legs after changing the compression stockings. b. If the skin is dry, a lotion may be used. c. If the patient has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying stockings. d. If the stockings become soiled by drainage, wash and dry according to instructions.

Answer: a Rationale: Assess the skin condition and neurovascular status of the legs. Report any abnormalities before continuing with the application of the stockings. Assess the patient's legs for any redness, swelling, warmth, tenderness, or pain that may indicate DVT. If any of these symptoms are noted, notify the health care provider before applying stockings.

Content: Testing stool for Occult blood As you enter your patients room to collect a Occult blood sample, You must include what information on the samples label? a. patient's name and identification number, time specimen was collected, route of collection, identification of the person obtaining the sample, and any other information required by facility policy. b. Patients name and birthday c. Patients initials, Date of birth, and room number d. patients name, time of the stool collected, and date

Answer: a Rationale: Having all of the correct information on the label insures that the sample will be processed as efficiently and returned to the right patient.

Content: Activity A nurse is educating a client on the use of a cane for ambulation, how far should the nurse instruct the client to advance the cane? a. 4 to 12 in (10 to 30 cm) b. 8 to 17 in (20 to 43 cm) c. 6 to 19 in (15 to 48 cm) d. 10 to 13 in (25 to 33 cm)

Answer: a Rationale: Moving in this manner provides support and balance. Moving the cane farther than 12 inches would not allow the client to use the cane for support and balance adequately.

Content: Using Venipuncture to Collect a Venous Blood Sample for Routine Testing and Order of Draw A nurse is performing venipuncture to the patient. What action is appropriate while performing venipuncture? a. After, disinfection, do not palpate the venipuncture site if possible. b. Do not inform the patient that he or she going to feel a pinch. c. When applying pressure, touch the insertion site gently. d. When using chlorhexidine to clean the skin, use a gentle side to side motion for at least 30 seconds.

Answer: a Rationale: Palpation is a potential cause of blood culture contamination, so do not palpate the venipuncture site after performing venipuncture.

Content: Employed seizure precautions and seizure management A nurse is in a client's room when the client begins to have a seizure. What position should the nurse place the client in? a) side-lying b) prone c) fowler's d) supine

Answer: a Rationale: Placing the client in side-lying position prevents the client from choking on their saliva or vomit, as it will flow out the mouth instead of in the throat.

Content: Applying and Removing Graduated Compression Stockings If patient has pain upon application to stockings, what should be your next step? Patient does not have an incision. a. Stop and notify provider. b. Keep applying stockings. c. Administer pain medication. d. Take a 5 minute break and try again.

Answer: a Rationale: Stop and notify provider because the patient could be developing a deep vein thrombosis. If patient had an incision, pain would be expected and pain medications could be administered but patient does not have an incision.

A nurse is testing a patient's stool for occult blood using FIT(fecal immunochemical test). Which answer choice indicates the correct action performed by the nurse during this procedure? a. With applicator, apply a small amount of stool from the center of the bowel movement onto one window of the testing card. With the opposite end of the applicator, obtain another sample of stool from another area and apply a small amount of stool onto second window of testing card. b. If using gFOBT, observe testing card for blue areas after 30 seconds for a positive test result for blood. c. After patient is done defecating, place specimen in non-sterile container. d. Use cotton applicator to mix the sample and spread sample over entire window.

Answer: a Rationale: Two separate areas of the same stool sample are tested to ensure accuracy. By using opposite ends of the wooden applicator, cross-contamination is avoided.

You're working with a newly licensed nurse on your floor. While removing an indwelling urinary catheter, what action by the newly licensed nurse indicates further teaching and intervention is required? a. The newly licensed nurse cut the inflation port b. The newly licensed nurse placed the catheter on the waterproof pad after removal and wrapped it in the pad c. The newly licensed nurse noted characteristics and amount of urine in the bag d. The newly licensed nurse placed the patient's bed back to the lowest position after removal

Answer: a Rationale: When removing an indwelling urinary catheter, the inflation port is never to be cut for deflation. Only the syringe must be inflated into the balloon inflation port. The indwelling urinary catheter is mandated to be placed on the waterproof pad and wrapped in the pad after removal. Characteristic and amount of urine must always be documented. The patient's bed must be placed back in its lowest position after the procedure.

Content: Using PPE Which statement is FALSE regarding the use of PPE? a. When wearing gloves, work from "dirty" areas to "clean" areas. b. Keep gloved hands away from face. c. If gloves become torn or heavily soiled, remove and replace. Perform hand hygiene before putting on the new gloves. d. Touch as few surfaces and items with your PPE as possible.

Answer: a Rationale: When wearing gloves, it is best that you work from "clean" to "dirty" areas to avoid further contamination.

Content: Fecal Occult Blood Test What is the most appropriate way to test for occult blood in stool? a. Collect stool specimens for serial guaiac testing three times from three different defecations. b. Collect stool specimens for serial guaiac testing three times from one defecation. c. Collect stool specimens for serial guaiac testing one time from three different defecations. d. Collect stool specimens for serial guaiac testing one time from one defecation.

Answer: a Rationale: You should collect stool specimens for serial guaiac testing three times from three different defecations to ensure you are not receiving a false positive result due to specific foods and medications.

A 79 year old male is transferred to the hospital from his assistive living facility. He was admitted for a fall, during the shift report the facility nurse stated he has no existing pressure injuries. When the client arrives to the acute unit what is the first step in preventing pressure injuries. a. The nurse will assess the patients risk for pressure injury and will continue to check on a regular scheduled basis. b.The nurse will order the client a nutritious meal and keep him hydrated. c. Foam cutouts and rings will be used in pressure spots to prevent injuries. d. The patient will be turned every 2 hours and use of a prophylactic dressing on bony prominence.

Answer: a Rationale: risk for pressure injury should be assessed and determined on admission and at regular intervals thereafter to prevent pressure injuries.

Content: Assessing a wound A nurse has just removed the dressing from a surgical wound. Which sign would indicate that the wound is infected? a. Erythema b. The wound has approximated edges c. The incision is clean and dry d. Staples intact

Answer: a Rationale: the signs of infection during a wound assessment are redness (erythema), warmth, pain, edema/swelling, and the presence of purulent drainage.

Content: Assisting a Patient With Ambulation Using a Cane A nurse has just taught her patient how to ambulate with her new cane. What could the patient say that might indicate she fully understood the nurses teachings? a. "I must hold the cane on my stronger side, close to my body before beginning to walk." b. " I can immediately get up out of bed once i sit up." c." The cane should hit at the height of my elbow and my elbow should be flexed about 30 degrees when holding the cane." d. " When i move the cane forward, it should advance 2 to 6 inches."

Answer: a Rationale:The patient should Hold the cane on the stronger side to help distribute the weight away from the injured side and prevents leaning. This also allows more room for the nurse to be able to assist if the patient went to fall that way.

nurse is preparing to administer medication to her patient. Upon entering the room which of the following should the nurse NOT use to identify her patient? (Select all that apply) a. Patients address b. Patients name c. Patients phone number d. Patients medical record number e. Patients date of birth

Answer: a and c Rationale: Identifying the correct patient ensures that the right patient receives the right treatment and procedures and reduces the risk for errors. The main identifiers are the patients name, medical record number, and the patients date of birth.

Your patient is using a cane for the first time. Which findings would demonstrate that the cane is the appropriate size for your patient? Select all that apply: a. The client's elbow is flexed about 15 degrees when holding the cane. b. The cane rises from the floor to the client's waist. c. The client's elbow is flexed about 45 degrees when holding the cane. d. The cane rises from the floor to the crease in the client's wrist.

Answer: a and d Rationale: The cane should rise from the floor to the crease in the patient's wrist and the elbow should be flexed about 15 degrees when holding the cane.

A patient has been combative with a nurse who is trying to give daily medications. What actions should be taken first to help the patient's combativeness? a. Assess the patient for pain and discomfort b. Increase frequency of patient observation c. Immediately use restraints d. Ask a family member or significant other to stay in the room with the patient

Answer: a, b, and d Rationale: Always see if there are things you can change in the patient's environment or about the patient's comfort before going to restraints. You must have a provider's order to use restraints.

A nurse is about to measure a patient's oxygen saturation level using a pulse oximeter. The nurse finds out that the patient has inadequate circulation to his extremities. What is another location the nurse could use to measure the patient's oxygen saturation? Select all that apply. a. earlobe b. bridge of the nose c. forehead d. wrist e. abdomen

Answer: a, b, c Rationale: If a patient has inadequate circulation to his upper extremities, the oxygen saturation level may not be accurate. The nurse must use another location to measure his oxygen saturation. The nurse could use the patient's earlobe, bridge of the nose, forehead, or the toe. The nurse would have to use an appropriate oximetry sensor depending on the chosen site. The wrist and abdomen are not locations a nurse could use to measure a patient's oxygen saturation.

Content: Safety Assessment Used During Clinical - Client Safety A nurse is preparing a room for a newly admitted client and must do one last check for safety. The nurse notices displaced items that immediately are considerations for safety and begins making adjustments. What adjustments to the room should the nurse make? Select all that apply. a. Make sure the call light and TV remote are readily available. b. Turn on the lights and set the room temperature appropriately. c. Raise the bed to the highest standard d. Open the bed by folding the top bed linens back. e. Disassemble and restock routine equipment to the stock room. f. Have another nurse be in the room to welcome and instruct the patient to communicate needs through the family.

Answer: a, b, d Rationale: A safety assessment regardless of when performed should aim to keep the patient's safety top priority. This includes positioning the bed with linens folded back in the lowest standard. Equipment, whether routine or special, should be in the room for rapid response or as needed measures. The client should also have belongings in reach to avoid having to overreach, leading to a fall.

Content: AIDET & Hourly Rounding A charge nurse is training a new graduate nurse regarding the hourly rounding. Which statement indicates the new graduate nurse needs further clarification? (select that all apply) a. "Hourly rounding has nothing to do with patient satisfaction scores." b. "Hourly rounding do not prevent patient falls." c. "Hourly rounding helps to reduce the use of call light." d. "Hourly rounding helps in early detection in skin breakdowns." e. "Hourly rounding can only bother the client."

Answer: a, b, e Rationale: Purposeful rounding is a proactive, systematic, nurse-driven, evidence-based intervention that helps nurses anticipate and address patient needs (McLeod & Tetzlaff, 2015). Although nurses may struggle to reorganize their day to permit hourly rounding, it is difficult to dismiss the growing body of research that suggests effective, purposeful rounding can promote patient safety, encourage team communication, and improve staff ability to provide efficient patient care. Nurses at Stanford Health Care identified eight behaviors of purposeful rounding, which are listed in Table 19-5. Be sure to note their recommendation to use the magic phrase before leaving a patient room, "Is there anything else I can do for you before I go? I have time." Research on hourly rounding in 14 hospitals revealed dramatic improvements: 12% increase in patient satisfaction scores 52% reduction in patient falls 37% reduction in call light use 14% decline in skin breakdowns

An emergency room nurse is taking vital signs on a pediatric patient who has asthma and is having trouble breathing. Which component should the nurse consider when applying the pulse oximetry device? (Select all that apply) a. Chose a probe that is appropriate for the patients age and size. b. The probe can only be applied to the patients fingers and toe. c. Verify that the patient is not allergic to adhesive before applying the probe. d. Check the patient's proximal pulse or capillary refill closest to the area applying the probe. e. Use the patients toe if one finger is too large for the probe.

Answer: a, c, d Rationale: Probes are available in adult, pediatric, and infant sizes choosing the appropriate size reduces the risk for inaccurate readings. Fingers are easily accessible but if there is not adequate circulation in the finger's; earlobes, the forehead, bridge of the nose, and toes can be used to obtain an accurate reading. Brisk capillary refill and a strong pulse indicate that there is adequate circulation at the site and a good area to apply the probe. If one finger is too large for the probe try using a smaller one first.

A nurse is making her hourly rounds. Which of the following are part of the 4 P's that should be addressed? Select all that apply. a. Pain b. Patience c. Potty d. Personal Effects e. Positioning

Answer: a, c, d, e Rationale: The 4 P's are pain, potty, positioning, and personal effects. These should be addressed each time you are doing your hourly rounds. By addressing these things while you are in the room, you can eliminate the potential for the patient to get out of bed and fall while attempting to go to the bathroom or reach for their eyeglasses or cell phone. Addressing positioning makes sure they are comfortable while avoiding pressure wounds.

Content: Obtaining a Urine Specimen from an Indwelling Urinary Catheter A nurse is preparing to obtain a urine specimen from a client's indwelling urinary catheter. Which of the following actions would be considered proper technique? Select all that apply. a. The nurse scrubs the aspiration port with an alcohol wipe and allows the port to air dry b. The nurse leaves the tubing clamped after obtaining the sample c. The nurse obtains a urine specimen from the urine collection bag attached to the catheter d. The nurse attaches a syringe to the port and aspirates 3 to 5 mL of urine e. The nurse slowly injects the urine into a sterile specimen container, being careful not to touch the inside or edge of the container

Answer: a, d, and e Rationale: Cleaning the aspiration port with alcohol reduces the chance of pathogens entering the closed system when the port is accessed. Collecting urine directly from the port ensures that the specimen is fresh, and 3 to 5 mL is generally an adequate amount. Slowly injecting the urine into the container reduces the risk of splashes, and it is important not to touch the inside or edge of the sterile container to avoid contamination. Failing to unclamp the tubing after obtaining a sample endangers the patient's health and puts them at risk for bladder overdistention and injury. Obtaining a urine specimen from the collection bag is not acceptable as the urine is not fresh and bacteria may be present.

Content: Using Venipuncture to Collect a Venous Blood Sample for Routine Testing and Order of Draw The nurse has a patient that needs a venous blood sample collected STAT. What are the incorrect steps the nurse performs when collecting this sample? Select all that apply. A. Not checking the specimen label with the patient's identification bracelet B. Not wearing gloves during the blood sample collection C. Using a Chlorhexidine, using a gentle back and forth motion D. Assisting the patient in a comfortable position

Answer: a,b Rationale: Wearing gloves is essential when dealing with any type of body fluids. Checking for confirmation of patient information ensures the specimen is labeled correctly for the right patient.

Content: Employing Seizure Precautions and Seizure Management The nurse is taking care of a patient who was in a motorcycle accident, and has now been placed on seizure precautions. Which precaution should the nurse take? Select all that apply. A. Make sure the rescue equipment is at the bedside B. Inspect the patient's environment for items that could cause injury C. Advise the family and caregivers to restrain the patient during a seizure D. Advise caregivers and family to not put anything in the patient's mouth

Answer: a,b,d Rationale: It is very important to have the patient's equipment ready in case the patient is having a seizure. Always make sure that the patient has no clutter to prevent any injuries, and never put anything in the patient's mouth or jaw.

Content: Assisting a Patient with Ambulation using a Walker The client calls out for assistance with help back to bed via walker. Which of the following procedures must the nurse put in place before she proceeds with the ambulation to secure safety? ( select all that apply) a. apply gait-belt b. place the walker on the side of the patient c. apply non-skid socks d. making sure all four legs remain on the ground e. once the pt has the walker, leave the room

Answer: a,c,d Rationale: Safety precautions shall be in place before any task. Non skid socks and the gait belt will help reduce the risk of falls. Making sure that all four legs are placed on the ground provides a broad base of support.Moving the walker and stepping forward moves the center of gravity toward the walker, ensuring balance and preventing tipping of the walker. Consider staying alongside the patient until the patient reaches the designated area/position.

Content: Incentive Spirometer How often should the nurse instruct the patient to perform incentive spirometry? a. 5-10 times every one to two hours b. 3-5 times every one to two hours c. 5-10 times every 24 hours d. 3-5 times every 24 hours

Answer: a. Rationale: Using the incentive spirometer 5-10 times every one to two hours helps to reinflate the alveoli and prevent atelectasis due to hypoventilation

Content: Using Venipuncture to Collect a Venous Blood Sample for Routine Testing and Order of Draw A nurse is caring for a client who has an order for a blood sample. Which action during the procedure by the nurse is correct? a. The nurse leaves the tourniquet tied until the entire sample is obtained. b. The nurse inserts the needle at 15 to 30 degree angle. c. The nurse makes sure the tourniquet is not too tight so there is no discomfort for the patient. d. After disinfecting the injection area, the nurse blots the area dry.

Answer: b

Content: Activity: Ambulation Using a Cane A nurse is preparing to assist her patient with ambulation. After the nurse has assisted the patient to the side of the bed, what should she assess for in the patient before continuing? _______ a.Range of motion in lower extremities b.Dizziness or lightheadedness c.Pain d.Behavior

Answer: b Rationale: Having the patient sit on the side of bed minimizes the risk for blood pressure changes (orthostatic hypotension) that can occur with position change.

You are performing an assessment on a 79 year old woman and notice she has muscle weakness, a disturbed gait, and dizziness. Based on the data, which is the most appropriate nursing diagnosis for this patient? a. Acute Pain b. Risk for Falls c. Impaired Memory d. Stress Overload

Answer: b Rationale: Acute Pain, depending on location, may impact a patient's mobility, but is not the most appropriate diagnosis. The patient possesses three physical characteristics of a fall risk, but also is at greater risk for falls due to her advanced age. Impaired Memory is not an appropriate diagnosis for this patient because no given evidence of a degenerative brain disease is mentioned, and Stress Overload is not an appropriate diagnosis because there is no given data of anxiety, panic attacks, or irritability.

A nurse is getting ready to put developer on the gFOBT testing card. What color should the card turn after the developer is added, if the result is positive? a. red b. blue c. green d. no color change

Answer: b Rationale: Any blue coloring on the card indicates a positive test result for blood.

What action is implemented for a patient who has a low fall risk? a. Establish an elimination schedule b. Make sure the floor is always clear of clutter c. Place a bed/chair alarm d. Move them closer to the nurse's station to be monitored

Answer: b Rationale: For a low fall risk patient, the floor being decluttered is the only required action out of these options. An elimination schedule is used for moderate to high risk patient's so they do not try to get out of bed on their own. A bed/chair alarm and moving closer to the nurse's station will only be necessary if the client is moderate or high risk and is confused or getting out of bed repeatedly without asking for assistance.

Content: Assisting a Patient with Ambulation Using a Cane When using a cane? which side of the body should the cane be placed? a. On the side of the affected leg b. On the strongest side c. On the side the patient prefers

Answer: b Rationale: If the patient uses the cane on the strongest side, he/she can distribute their weight away from the affected leg. This also helps to prevent leaning.

A nurse is assessing a patient's IV site for signs and symptoms related to phlebitis. What should the nurse be looking for? Swelling, coolness, pallor Redness, swelling, warmth Bruising, coolness, tenderness Warmth, tenderness, petechiae

Answer: b Rationale: Phlebitis is inflammation of the blood vessel. Tell-tale signs of inflammation include redness, swelling, and warmth

A nurse has finished performing her tasks in a client room, and is removing her PPE. They are wearing a respirator. Which of the following is correct: A In the client's room the nurse removes their gloves, followed by their gown, and then goggles. They leave the room before removing their respirator. B The nurse removes their gloves, then their goggles, followed by the gown in the client's room. The nurse waits until they have left the room and the door has closed to remove the respirator. C The nurse waits until they have left the client's room to remove their PPE. D In the client's room, the nurse removes their gloves and then their gown. They wait until they have left the room to remove their goggles and respirator.

Answer: b Rationale: Proper removal prevents the spread of microorganism. The nurse should remove the respirator after leaving the client's room to prevent their contact with airborne particulates.

Content: Safety Assessment Used During Clinical - SBAR Communication A nurse notices a change in client status that requires immediately intervention authorized by the provider. How will the nurse engage in accurate communication with the provider? a. Communicate the situation, background, all vitals, and review of order b. Communicate the situation, background, assessment, and recommendation c. Communicate the situation, background, age, and recommendation d. Communicate the severity, background, assessment, and review of orders

Answer: b Rationale: SBAR stands for situation, background, assessment, and recommendation. Using the SBAR format for communication among health officials allows hand-off communication to be consistent, clear, structured, and easy to use. It also supports safe practice.

Content: Ambulation with a walker The Nurse is assisting a patient with a walker to move from the bed to a chair. Where should the nurse stand to provide support and prevent injury in case of a fall? a. Directly in front of the patient, holding the handgrips of the walker to provide steadiness. b. Slightly behind the patient, on one side. c. On the other side of the bed in order to help push the patient to a standing position. d. In front and to the side of the patient with arms out in a ready-to-steady position.

Answer: b Rationale: Standing slightly behind and on the side of the patient allows the nurse to be in a good position to steady or catch the patient if dizziness or a fall occurs. This also helps the client to stand and walk in a fully upright position. Standing in front of the patient and walker, or behind them to push, does not put the nurse in a good position to support or catch the patient quickly.

Content: Cleaning a Wound and Applying a Dry, Sterile Dressing You are removing the old dressing from your patients wound, when you notice that some of the dressing is stuck to the wound. How should you proceed to remove the dressing? a. Use tap water to soak the dressing until it is loosened b. Use a small amount of sterile saline to loosen and remove it c. Gently pull until the bandage is loosened d. Call the provider for assistance

Answer: b Rationale: Sterile saline moistens the dressing for easy removal and minimizes damage and pain. Wound care and procedures require the use of sterile items, so tap water cannot be used. A provider is not needed, as the nurse can remove it themselves. Pulling on the bandage can cause further damage to the tissue.

Content: Hygiene When providing oral care to a patient who has dentures, where should the dentures be stored? a. In a paper towel at patient's bedside b. in a cup of cold water c. in the bathroom beside the sink d. on the patient's bedside table within reach

Answer: b Rationale: Storing in water prevents warping of dentures. Proper storage prevents loss and damage.

Content: Testing stool for occult blood Which of the following is NOT a technique used when testing a stool sample for occult blood? a. Allow the sample to dry before adding the developer. b. Test from the same area of stool in both windows. c. Compare results to the control line. d. Use opposite ends of the wooden applicator for each window of the testing card.

Answer: b Rationale: Test should come from two separate areas of stool to get a more accurate test result. Allowing the sample to dry ensures that it penetrates the test paper. Control line ensures the test results are accurate. Using opposite ends of the wooden applicator avoids cross-contamination.

Content: Assisting the Patient with Oral Care The nurse is teaching the client about the importance of oral care. Which of the following client actions indicates that the client understands the importance of oral care? a) "I will place my toothbrush at a 90-degree angle to the gum line and brush back and forth across each surface of each tooth"b) "I will place my toothbrush at a 45-degree angle to the gum line and brush back and forth across each surface of each tooth"c) "I will use mouth rinse before brushing my teeth"d) "I will use a soft brush for oral care"

Answer: b Rationale: The 45-degree angle of brushing permits cleansing of all tooth surface areas.

A nurse is assessing the wound of a patient and notes that there is full-thickness skin loss and a small amount of slough visible. There is no muscle, tendon, or bone exposure. Which stage pressure ulcer is the nurse assessing? a. Stage I b. Stage II c. Stage III d. Stage IV

Answer: c Rationale: The skin in a stage I pressure injury is intact. Stage II pressure injury is of partial-thickness skin loss. A stage IV pressure injury has full-thickness loss of skin, but muscle, tendon, ligament, cartilage or bone is exposed in the ulcer, so the nurse is assessing a stage III pressure injury in this scenario.

The third check of medication administration can be completed by rechecking the label on the container against the MAR before returning to its storage place or a. while preparing the medication. b. before giving the medication to the client. c. after giving the medication to the client. d. when removing the medication from the drawer.

Answer: b Rationale: The label should be read: 1. When the nurse reaches for the unit dose package or container. 2. After retrieval from the drawer and compared with the eMAR/MAR, or compared with the eMAR/MAR immediately before pouring from a multidose container. 3. Before giving the unit dose medication to the patient, or when replacing the multidose container in the drawer or shelf. Answers a and d would be done during the second check, and you should not give the medication to the patient before completing the third check.

Content: Administering Medications via a Gastric Tube (GT) The patient has a percutaneous endoscopic gastrostomy tube (PEG tube) and needs medications. Which would be the correct step in this procedure? a. Assist the patient to a supine position. b. Note the amount of any gastric residual. c. Allow the medications to enter the stomach via push infusion. d. Do not flush the tube between medication doses.

Answer: b Rationale: The nurse would need to note the amount of gastric residual. The patient needs to be in a high-Fowler's position. The medications need to be given via gravity infusion. The tube needs to be flushed with 5- 10-mL of water between medication doses.

Content: Performing Irrigation of a Wound The nurse is caring for a patient who has been bedbound since their automobile accident. The patient has developed a stage 3 pressure ulcer. The nurse needs to perform wound irrigation. Which technique would be incorrect when providing this type of care? a. Keep the tip of the syringe at least 1 inch above the upper edge of the wound. b. Once the wound is clean, do not dry the surrounding skin. c. After securing the dressing, label it with date, time, and initials. d. If the dressing of the wound becomes saturated, you have to change it.

Answer: b Rationale: The nurse would use a gauze sponge to dry the surrounding skin and then apply a skin protectant. It is important to dry the surrounding skin of a wound to prevent the growth of microorganisms.

Reference: AIDET & Hourly rounding worksheet in module 2 Content: Applying and Removing Graduated Compression Stockings A nurse is removing graduated compression stockings what action should the nurse take while removing? Grip the bottom of stocking with fingers by the heel and smoothly pull the stocking off the patient's leg Grasp top of stocking with your thumb and fingers and smoothly pull stocking off inside-out to heel and support foot and ease stocking over it Hold the top of stocking rolling it down until the heel sliding the stocking off easily Support the foot by pulling the stocking off quickly

Answer: b Rationale: This preserves the elasticity and contour of the stocking. It allows assessment of circulatory status and condition of the skin on the lower extremity and for skincare.

Content: Oral Hygiene/Denture Care A nursing student has been providing care for an elderly patient and is preparing to assist with their oral care. The patient has dentures. What statement by the nursing student requires intervention from the instructor? a. It is important to clean dentures daily in order to prevent buildup of food and plaque. b. Dentures are to be worn at all times, except when being cleaned, in order to promote self-confidence and positive body image. c. 4x4 gauze pads can be used to assist in removing denture plates, using a slight rocking motion. d. A soft-bristled toothbrush should be used to clean gums, mucous membranes, and the tongue before replacing dentures.

Answer: b Rationale: This statement would require intervention from the nursing instructor. Dentures should not be worn 24/7 due to the increased risk of denture stomatitis, or irritation of the oral tissues. It is recommended that dentures are to be removed at night.

Which of the following are true regarding stool specimen collection? a. Patient can relieve stool into toilet. b. Obtain specimen before antibiotics are administered. c. Patient can urinate/menstrual bleed into same container as stool. d. Administer laxative for patient to pass a bowel movement.

Answer: b Rationale: To avoid decreasing the amount/type of bacteria you always receive a stool specimen before administering antibiotics.

Which of the following is NOT a guideline for effective use of PPE? a. Work from least dirty to most dirty area when wearing gloves b. Use soiled gloves to touch or adjust other PPE c. Personal glasses are not a substitute for goggles d. Choose appropriate PPE based on the type of exposure/precautions e. Remove and replace torn or heavily soiled gloves

Answer: b Rationale: Use soiled gloves to touch or adjust other PPE increase the risk of contaminate self and others which should be avoid throughout patient care.

When you are evaluating compression stockings, what do you need to check for? a. Be sure powder and lotion have not been applied. b. Ensure the top or toe opening does not roll with movement. c. Both compression stockings are the same size on both legs. d. Have compression stockings inside out.

Answer: b Rationale: When compressions stockings edges are rolled, it can cause excessive pressure which will interfere with circulation. Powders and lotions can be used and stockings can be different sizes on both legs but they should be right side out.

Content: Three Checks and Rights of Medication While preparing to administer medication the nurse compares the medication label against the MAR, This is an example of? a. first check of medication administration b. second check of medication administration c. third check of medication administration

Answer: b Rationale: the second check of medication administration is preparing the medication while looking at the medication label and checking it against the MAR.

Content: Teaching a Patient to Use an Incentive Spirometer A client returns from having abdominal surgery. The nurse is doing education on incentive spirometer use. Which of the following client actions indicates that the client is using the incentive spirometer correctly? Select all that apply. a) The patient inhales normally and then places their lips securely around the mouthpiece b)The patient inhales slowly and as deeply as possible through the mouthpiece without using their nose c) The patient holds their breath and counts to 20d) The patient uses the incentive spirometry 5 to 10 times every 1 to 2 hours

Answer: b and d Rationale b: Inhaling through the nose would provide an inaccurate measurement of inhalation volume. The inhalation indicator on the spirometer moves during inhalation, to gauge lung expansion. Rationale d: Using the incentive spirometer 5 to 10 times every 1 to 2 hours helps to reinflate the alveoli and prevent atelectasis due to hypoventilation

Content: Assisting a Patient with Ambulation Using a Walker A nurse is assisting a client with ambulation using a walker. Which of the following actions would not be considered proper technique? Select all that apply. a. Ensuring that the walker is at the appropriate height for the patient b. Using a walker on the stairs c. Having the patient wear non-skid shoes or slippers d. Instructing the patient to pull on the walker to get up e. Having the patient move the walker forward 10-12 inches and set it down, before moving forward

Answer: b, d, and e Rationale: Using a walker on the stairs is dangerous as the patient may lose their balance and fall. The patient must not pull on the walker to get up; the walker could tip over or become unbalanced, leading to a fall or injury. The patient should be instructed to move the walker forward 6 to 8 inches and set it down, making sure all four feet of the walker are on the floor, before stepping forward. It is important to ensure that the walker is at the appropriate height for the patient. Having the patient wear non-skid shoes or slippers is considered proper technique as it reduces the risk of falls.

Content: Indwelling Urinary Catheter Care Which of the following actions by the nurse would indicate further teaching is needed? Select all that apply. a. Holding the catheter securely at the meatus with the nondominant hand. Using the dominant hand to inflate the catheter balloon. b. Injecting ½ of the sterile water supplied in a prefilled syringe. c. Securing the drainage bag below the level of the bladder. d. Asking the patient to take several slow deep breaths. e. Quickly and gently removing the catheter.

Answer: b, e Rationale: The manufacturer provides appropriate amount of sterile water for the size of the catheter in the kit; as a result, use the entire syringe provided in the kit. Slow gentle removal, not quick remove, prevents trauma to the urethra. Bladder or sphincter contraction could push the catheter out. The balloon anchors the catheter in place in the bladder. Securing the drainage bag below the level of the bladder facilitates drainage of urine and prevents the backflow of urine. Slow deep breathing helps to relax the sphincter muscles.

Content: Obtaining a Urine Specimen From an Indwelling Urinary Catheter A nurse has an order to get a urine specimen from a patient with an indwelling urinary catheter. How should the nurse go about getting the urine specimen? a. Take the indwelling catheter out and let the patient urinate into the specimen cup. b. Clamp the catheter drainage tubing or bend it back on itself distal to the port and then obtain the specimen. c. Obtain the specimen from the urine in the catheter bag. d. Clamp the catheter drainage tubing for 2 hours letting the urine collect in the tube and then obtain the specimen.

Answer: b. Rationale: When collecting a urine specimen from an indwelling catheter you should never clamp the tubing for more than 30 minutes. Leaving it clamped for an extended period of time leads to overdistention of the bladder and can become unsterile. The specimen also needs to be fresh urine.

Content: Laboratory Specimen Collection: Testing Stool for Occult Blood When a nurse is testing a patient's stool for occult blood, how long should the nurse wait before developing? ______ a.1-2 minutes b.1 minute c.3-5 minutes d.5-6 minutes

Answer: c Rationale: If the nurse waits 3-5 minutes before developing, they have allowed adequate time for the sample to penetrate the test paper and dry. The developer will react with any blood in the stool. The nurse following the manufacturer's instructions will promote the accuracy of results.

A patient will be using a walker for the first time. You adjust the walker to fit the patient. Which finding below demonstrates that the walker appropriately fits the patient? The patient's back is mid-line with the walker's crossbar. The crossbar is lined even with the greater trochanter. The elbows are flexed at about 30 degrees when hands are placed on the grips. 2-3 finger length distance between the hands grips and the wrists.

Answer: c Rationale: Walkers provide stability and security for patients with insufficient balance and strength. Regardless of the type of walker being used, the back legs of the patient are between the walker with arms relaxed at the side. Elbows flexed at 30 degrees allows for better stability.

A nurse manager is observing a new nurse performing a situational assessment for a newly admitted client. Which of the following situations indicates the new nurse needs further teaching? a. Noting that the patient utilizes a bedside commode and makes sure it is near the bed. b. Assessing for the presence of any tubes, such as gastric tubes, chest tubes, surgical drains, or urinary catheters. Assess patency of device and insertion site. c. Assessing the room for clutter and placing a thin rug to prevent the patient from getting cold feet when they walk around. d. Assessing the patient's level of consciousness, orientation, and speech.

Answer: c Rationale: The living space/hospital room should be assessed for clutter and hazards. In this statement, a thin rug would be a hazard for slipping. Additionally, excess equipment, supplies, furniture, and other objects should be removed from rooms and walkways. Pay particular attention to high traffic areas and the route to the bathroom. All are possible hazards and could cause the patient to fall. Making sure the bedside commode is near the bed at all times prevents falls related to incontinence or trying to get to the bathroom. Assessing for the presence of any tubes allows for identification of problems and ensures patency of devices. Problems with the patient's level of consciousness, orientation, speech, behavior, or affect may signal a situation requiring immediate action.

2. Content: Hygiene A nurse is preparing the give oral care to a comatose, or unconscious patient. What would be the most appropriate tool to use to prevent the patient from aspirating? a. a basin b. towel c. suction toothbrush d. toothpaste

Answer: c Rationale: A suction toothbrush provide removal for extra water, saliva, toothpaste, etc. Without the use of suction, the patient could aspirate and cause further problems.

Content: Testing Stool for Occult Blood A nurse is using a guaiac fecal occult blood test (gFOBT) to assess for the presence of blood in a patient's stool sample. What option best describes how long the nurse should wait for the results after the developer is placed? a. The nurse should wait one minute. b. The nurse can immediately view the results after applying the developer. c. The nurse should read the manufacture's recommendation to decide how long to wait. d. The nurse should always wait three minutes before viewing the results.

Answer: c Rationale: Although many developers require waiting three to five minutes before viewing results, reading the manufacture's protocol will ensure the most accurate result.

Content: Assessing wounds A newly trained nurse has gathered all materials for surgical suture removal. The client states that he is in pain and would like to wait to do the procedure. What action by the nurse is appropriate? a. The nurse gives the client analgesic medicine and then proceeds with the procedure immediately. b. The nurse asks the patient to rate and describe his pain, decides the client is not in enough pain and proceeds with the procedure after 15 minutes to give the patient time to forget about it. c. The nurse assesses the clients pain, administer appropriate prescribed medication and allows time for medication to achieve effectiveness before proceeding. d. The nurse delegates the task to a unlicensed nursing assistive personnel after assessing the clients pain, administer the appropriate medication and allowing time for medication to achieve effectiveness.

Answer: c Rationale: Assess the patient for possible need for nonpharmacologic pain-reducing interventions or analgesic medication before beginning the procedure. Administer appropriate prescribed analgesic. Allow enough time for the analgesic to achieve its effectiveness before beginning the procedure. The removal of surgical sutures is not delegated to nursing assistive personnel (NAP) or to unlicensed assistive personnel (UAP). Depending on the state's nurse practice act and the organization's policies and procedures, the removal of surgical sutures may be delegated to licensed practical/vocational nurses (LPN/LVNs).

Content: AIDET & Hourly Rounding A nurse is providing wound care to an elderly UTI client. What shows the nurse understands the letter D in AIDET? a. "Hi, I'm a nursing student at UAB." b. "Thank you, Mr. Jackson. Before I leave, is there anything I can do for you?" c. "For the next half hour, I will be doing a complete physical assessment before your UTI procedure." d. "Are you experiencing any discomfort at this time?"

Answer: c Rationale: Duration- Gave time expectation of how long test, procedure, appt, etc. will take - Verbalized next step

Content: Fall Prevention A nurse is assisting a patient out of bed with ambulation using a cane. What would be the nurse's first priority before assisting the patient? a. Give the patient a pair of regular socks to avoid skin to floor contact. b. Put on non-sterile gloves. c. Lower the bed to the lowest position and lock the brakes. d. Place a nonskid mat on the floor beside the patients bed.

Answer: c Rationale: It is always important that you do not assist a patent with ambulation before ensuring the bed at its lowest position and the wheels are locked. Patients should be given nonskid socks upon ambulation. Non-sterile gloves and a nonskid mat are not required for assisting a patient out of bed with ambulation .

A nurse is assisting a patient with ambulation using a cane. In what sequence should the nurse instruct the patient to advance her steps using the cane? a. While supporting his or her weight on the stronger leg and the cane, have the patient advance the stronger leg forward to finish the step. b. While supporting his or her weight on the weaker leg and the cane, have the patient advance the weaker leg forward to finish the step. c. While supporting the patient's weight on the weaker leg and the cane, have the patient advance the stronger leg forward to finish the step. d. While supporting his or her weight on the stronger leg and the cane, have the patient advance the weaker leg forward to finish the step.

Answer: c Rationale: Moving in this manner provides support and balance.

Content: Aidet and hourly rounding Which statement by a nursing student at clinicals indicates the need for further teaching regarding hourly rounding? a. "I should introduce myself to the patient and family members and write my name of the white board" b. "It is important to tell my patient how frequently I will be rounding and coming into their room" c. "I do not need to ask the patient if they need to use the restroom because that is the PCT's job" d. "I will perform hand hygiene as I go in and as I exit each room so I don't spread germs from room to room"

Answer: c Rationale: Potty is one of the 4 P's that is crucial to address during rounding. While PCT's do assist with getting patients to the bathroom, it is also part of the nurses responsibility and should be addressed during each round.

A patient is not cooperating with their nurse's wishes. A good nurse knows that an extremity restraint should be used when... The nurse is tired of reasoning with the patient. The patient needs to be punished for not listening. All other methods have been explored and the patient is at risk of hurting themselves. The risks of using the restraint outweigh the benefits

Answer: c Rationale: Restraints should only be used when all other options have been tried and none have worked. The benefits of using the restraint must outweigh the risks and it must be for the client's safety.

A nurse enters a patient's room and observes the following things, which of the following situations requires immediate intervention to prevent a fall? a. The patient has clothes scattered on all of the furniture in the room. b. The patient is wearing their non-skid footwear. c. The patient has spilled their water on the floor. d. The patient's family is circled around the entire bed.

Answer: c Rationale: Spilled water is a major fall risk. Keeping the floor clutter-free and clean is a priority. Family around the bed can cause a crowded room, but it is not the biggest fall risk stated. Clothes scattered on furniture is not a big risk as long as there is not any on the floor. Wearing non-skid footwear will help minimize the risk of falls.

Content: Teaching a Patient the use of an Incentive Spirometer A nurse is educating a client on how to use an incentive spirometer. The nurse instructs the client to do it every 2 hours. Which state by the client indicates he understands the teaching? a) "I will exhale hard into the mouthpiece and mark how high the ball went." b) "Using the spirometer is only necessary for people with lung problems." c) "I will inhale deeply onto the mouthpiece and hold my breath for 3 to 5 seconds, every 2 hours, as this will prevent lung problems." d) "I will inhale then exhale immediately into the mouthpiece."

Answer: c Rationale: The client should understand that he or she should inhale into the incentive spirometer rather than exhale. The client should also understand this is to prevent lung problems, and not only intended for people with current lung problems.

Content: Oral Hygiene A nurse is preparing to assist an elderly client with their morning oral care. What task should the nurse prioritize implementing first? a. Assess the status of the client's oral cavity. b. With a soft-bristled toothbrush, begin brushing the client's teeth and gums being sure to brush the tongue. c. Assess the patient's physical activity limitations and overall ability to assist with their oral care. d. Ensure the patient is in a comfortable, upright position.

Answer: c Rationale: The nurse should first assess her client's ability to help with their oral care and determine what the client is able to accomplish on their own, in order to maintain a sense of independence.

Content: Teaching a Patient How to Use An Incentive Spirometer A student nurse is teaching a patient how to use an incentive spirometer. Which of the following would suggest the student nurse needs further teaching? a. The student nurse places a pillow or folded blanket over chest or abdomen. b. The student nurse uses a nose clip. c. The student nurse instructs patient to hole breath for five seconds. d. The student nurse encourages patient to complete exercises 5 to 10 times every 1 to 2 hours, if possible.

Answer: c Rationale: When the patient cannot inhale any longer, the student nurse should instruct the patient to hold breath for three seconds. If the patient holds their breathe for too long, they could become lightheaded.

Content: Three checks and the "rights of medication administration" A nurse has just retrieved a multi-dose vial from the medication drawer. What should she do next to complete the second check? a. Draw up medication from the multi-dose container. b. Complete the correct dosage calculation before drawing up the medication. c. Compare the medication label with eMAR/MAR. d. None of these

Answer: c Rationale: comparing the label to the eMAR/MAR should be done immediately before drawing up or giving any medication.

Content: Assisting a Patient with Ambulation Using a Walker When helping a patient ambulate with a walker, where should the nurse stand to assist and steady the patient? a. The nurse should stand directly on the side of the patient. b. The nurse should stand back and watch while the patient steadies themselves. c. The nurse should stand slightly behind the patient, on one side. d. The nurse should stand in front of the patient, on one side.

Answer: c. Rationale: The nurse should stand behind the patient while holding the gate belt. This helps the patient feel more comfortable while ambulating and helps the nurse have some control in case the patient began to fall.

Content: Skill 9-11: Applying and Removing Graduated Compression Stockings A charge nurse is evaluating a nurse applying graduated compression stocking to a client. Which statement would need the charge nurse to intervene? a. "I'll make sure removing stockings daily and inspecting legs." b. "I assess the patient's extremities at least every shift for skin color, temperature, sensation, swelling, and the ability to move." c. "I evaluate stockings to ensure the top or toe opening does not roll with movement." d. "There is no need to worry my patient may develop deep vein thrombosis or phlebitis since the client has the graduated compression stocking on."

Answer: d Rationale: Remove stockings daily and inspect legs. Wash and air-dry, as necessary, according to manufacturer's directions. Assess the patient's extremities at least every shift for skin color, temperature, sensation, swelling, and the ability to move. If complications are evident, remove the stockings and notify the primary care provider. Evaluate stockings to ensure the top or toe opening does not roll with movement. Rolled stocking edges can cause excessive pressure and interfere with circulation. Despite the use of elastic stockings, a patient may develop deep vein thrombosis or phlebitis. Unilateral swelling, redness, tenderness, pain, and warmth are possible indicators of these complications. Notify the primary care provider of the presence of any symptoms.

Content: Patient Identification A patient can be identified by using at least two patient identification methods. Which of the following is not a patient identification method a. check the name on the patient's identification band b. check the identification number on the patient's identification band c. check the birth date on the patient's identification band d. ask the patient to give a reason why they are in the hospital

Answer: d Rationale: A patient can be identified by checking the name, identification number, or birthdate on the patient's identification band. A patient can also be identified by asking them to sate his or her name and birth date. Asking a patient to give a reason why they are in the hospital is not a way of identifying a patient. They could give an incorrect answer, or many patient's could come to the hospital for the same reason.

Content: Medications A nurse is administering medication via a gastric tube. She has just checked the tube placement. Which of the following should she do next? a. Pour water into the tube via a syringe without a plunger and allow the water to enter the stomach through gravity infusion b. Put on gloves to prevent contact with body fluids c. Assist the patient to high-Fowler's position to reduce risk of aspiration d. Note amount of any residual and replace back into the stomach according to facility policy

Answer: d Rationale: Although research has found that the benefits of replacing residual back into the stomach are unknow, it is generally accepted practice. Overall, doing this avoids fluid or electrolyte imbalance.

Content: AIDET & Hourly Rounding A nurse is doing Hourly Rounding, what are the nurse main goals of hourly rounding and AIDET? Knock on the door, hand hygiene, introduce, ask if need anything and hand hygiene before leaving 2 step identify the patient, perform physician order, and make sure call light is within reach Check on patient every 30 minutes addressing 4 p's Address the 4 p's, assess, introduce, duration, explain, and thank you, conduct an environmental assessment, and complete scheduled task.

Answer: d Rationale: At the hospital, the nurse is responsible for doing hourly rounding and AIDET making sure the patient is safe.

Content: Ambulation with a cane A nurse is helping a patient adjust to ambulation with a cane. Which statement indicates the patient needs further education? a. "If I sit on the bed for a minute before getting up, I am less likely to get dizzy." b. "I will advance the cane 4-12 inches ahead for every step." c. "When I climb stairs, I will advance my stronger leg first." d. "I will hold my cane on my weaker side."

Answer: d Rationale: Cane should be held on the patient's stronger side. Not standing immediately reduces effects of orthostatic hypotension. 4-12 inches is an appropriate distance, and the stronger leg should be used first when going up stairs.

Content: Assisting a Patient with Ambulation Using a Cane Which patient would be able to safely ambulate with a cane? a. A 56 year old female who is recovering from a knee surgery and cannot bear weight on her left side b. A 82 year old male who has severe hand weakness and complains of dizziness c. A 68 year old male who has excellent balance but is unable to bear weight on his right side d. A 73 year old female that has been diagnosed with dementia and has poor balance but is able to bear weight on affected leg

Answer: d Rationale: Canes are used to assist patients with poor balance and are able to bear weight on their affected leg. A person who experiences dizziness or lightheadedness cannot safely ambulate with a cane. Patients with dementia can ambulate with a cane if he/she has adequate mobility.

A nurse is preparing to apply compression stockings to one of her patients. She assess the patient's right leg and notices that it is red, swollen, warm to the touch, and very painful. What is the correct next step? a. Proceed with the application of the compression stocking. b. Document her findings and return in 2 hours to apply the compression stocking. c. Deeply massage the patient's leg to relieve any discomfort. d. Alert the provider, as these are signs of a DVT.

Answer: d Rationale: Deep vein thrombosis is a serious condition because the blood clot could dislodge from the vein in the leg and travel to the lungs, causing a pulmonary embolism. These signs and symptoms that the nurse noticed may indicate the patient has a DVT. It is important to notify the provider of these findings. She would not proceed with the application of the stocking or document her findings and come back later because that ignores the seriousness of the DVT. She would not deeply massage the patient's leg because that could physically dislodge the blood clot.

Content: Activity A nurse is assisting a client with ambulation using a cane, how should the nurse instruct the client to distribute their weight when standing? a. Put all of your weight onto the cane. b. Distribute your weight evenly between your feet. c. Put all of your weight onto your weaker foot. d. Distribute your weight evenly between your feet and the cane.

Answer: d Rationale: Evenly distributed weight between the feet and the cane provides a broad base of support and balance. The other choices are incorrect ways to assist a patient with ambulation using a cane.

Content: Administering Oral Medications You have four patients who all need medication on your morning rounds. Of these, which patient would you not question/withhold an oral medication if prescribed? a. Patient A who suffered a stroke the previous night and is awaiting a swallowing test. b. Patient B who has been awake since 0400 due to vomiting. c. Patient C who is in an induced coma. d. Patient D who is 1 day post-operative of a minor elective surgery and awaiting discharge.

Answer: d Rationale: If patient cannot swallow, is unconscious or NPO, does not have a gag reflex, or is experiencing nausea or vomiting, withhold the oral medication, notify the primary health care provider, and complete proper documentation. Patient A is at risk for dysphagia because of the stroke and has not completed a swallowing test, Patient B has been vomiting recently, and Patient C is unconscious, so Patient D is the only patient eligible for oral medications at this time.

Content: SBAR/ Safety Assessment Form A nurse is completing a safety assessment on a patient and notices a nasal cannula. What should the nurse check for when assessing the patient? a. Redness or swelling around the site. b. Date of insertion. c. Drainage bag is below level of bladder. d. Tubing is free of kinks and attached to wall.

Answer: d Rationale: Redness or swelling around the site may be present if patient has an IV. Date of insertion is used for feeding tubes, Foley catheters, and IVs. Drainage bag below bladder refers to a patient who has a catheter.

A new nurse with the help of the charge nurse are teaching a patient, recently prescribed a walker, how to properly ambulate with the new assistive device. What instruction explained by the new nurse indicates to the charge nurse that further teaching is needed? a. All four of the feet of the walker should be on the floor before the patient moves their feet. b. The walker should be moved 6-8 inches forward in front of the patient. c. Patients should move one foot into the walker and support their weight on the handgrips before moving the remaining foot. d. Move the walker forward a few inches simultaneously with the movement of the first leg.

Answer: d Rationale: The patient should wait to move their feet until the walker is firmly planted with all four feet on the ground. This prevents the walker from tipping or sliding when the patient moves, and becomes a steady object to keep their balance when ambulating.

Content: Assisting a Patient with Oral Care A student nurse is assisting a cognitively impaired patient with oral care. Which of the following would suggest the student nurse needs further teaching? a. The student nurse breaks the task into small steps. b. The student nurse provides distraction, such as playing favorite music, while providing care. c. The student nurse withdrawals and attempts to try again if the patient strongly refuses care. d. The student nurse explains to the patient what to do, without showing the patient first.

Answer: d Rationale: The student nurse should start the activity, showing the patient what to do, then allow the patient to take over. Beginning the activity first, can prevent error and injury from occurring.

Content: Employing Seizure Precautions and Seizure Management A nurse is assessing the patient who shows pre-existing condition that increase patient's risk for seizure activist. What is NOT appropriate assessment? a. assess for the occurrence of an aura b. assess for pupil size c. assess for the presence or absence of repeated involuntary motor activity d. assess circumstances after the seizure, such as visual, auditory, or olfactory stimuli.

Answer: d Rationale: When assessing patient who show pre-existing condition for seizure, it is appropriate to assess circumstances before the seizure, such as visual, auditory, or olfactory stimuli, tactile stimuli, emotional or psychological disturbance, sleep or hyperventilation. Patient shows symptoms before the actual seizure, so nurse should assess for the sensory stimuli before it happens.

Content: Asepsis and Infection Control A nurse is preparing to leave the room after treating a patient with standard precautions. Which order should the nurse remove (doff) her PPE (Personal Protective Equipment)? a. Gown, Mask, Gloves, Goggles b. Mask, Gown, Goggles, Gloves c. Goggles, Gloves, Mask, Gown d. Gloves, Gown, Goggles, Mask

Answer: d Rationale: You start by removing the most contaminated ppe first, which would obviously be the gloves because that is what you use to handle the patient. Then you would remove your gown by untying it and pulling it away from your body and ball it up gently to prevent spread and properly dispose of it. Lastly, you would remove your goggles and mask. Don't forget hand hygiene!

A nurse is performing an assessment on a client. Practicing the skills of AIDET, what should the nurse remember to do? (select all that apply). a. Quietly gather supplies and do the assessment in silence, to keep the client comfortable. b. Introduce themselves to the client before the assessment and acknowledges client by name. c. Speak in a precise, scholarly language. d. Thoroughly explain the assessment. e. Thank client upon conclusion of the assessment.

Answers: B, D, E Rationale: AIDET stands for Acknowledge, Introduce, Duration, Explanation, and Thank you. The nurse must speak to the client at all times to introduce themselves explain the procedure. The nurse must speak in a language that the client can understand.

Question: A nurse is preparing to irrigate a patient's wound. Which of the following nursing actions would the nurse use to preform wound care irrigation. Select all that apply A.the nurse preforms the action of setting up a sterile field and uses sterile equipment B.the nurse cleans the wound from least to most contaminated C.the nurse discontinues irrigation after 2 minuets and once half of the solution in the syringe has been used D.the nurse uses a high-pressure irrigation flow to ensure the wound is thoroughly clean E.during the wound irrigation, the nurse notices bleeding from the wound and continues irrigating until there is no more signs of bleeding F.once the wound is cleaned, the nurse dries the surrounding skin using gauze sponge

Anwser: A,B,F Rationale: Sterile technique maintain surgical asepsis and is used for irrigation. Wounds should always be cleaned from least to most contaminated to avoid further contamination and prevent infection. Irrigation should be discontinued when the solution from the wound flows out clear. High pressure irrigation flow should not be used because it may cause patient discomfort as well as damage to granulation tissue. If during wound irrigation, bleeding is noticed the nurse should stop the procedure, assess the patient, take vitals, report the findings to the provider, and document the findings. Once the wound is cleaned, the surrounding area should be dried because moisture provides a medium for the growth of microorganisms.

A patient has been trying to take out their IV in their left arm. What would be the first type of restraint the nurse would consider asking the physician to order? a. The nurse would consider an extremity restraint. b. The nurse would consider a waist restraint. c. The nurse would consider a cloth mitt to the right arm. d. The nurse would consider putting up the bed rails.

Anwser: C Rationale: You start with the least invasive restraint when applying restraints. An extremity restraint, as well as the waist restraint, would be too invasive. The bed rails would not be the proper restraint to use in this situation because it would not prevent the patient from taking out their IV.

Content: Administering Medications via a Gastric Tube (GT) Question:When preparing to administer medication to a patient via GT, what nursing intervention would the nurse implement? A.Position the patient in a supine position before administering medication B.Do not flush in between administering medications, flush after all the medications have been administered C.When gathering the medications that are to be given, the nurse should keep them together and administer them at the same time D.If pills or capsules are to be given, check with pharmacy or drug reference to verify the ability to crush tablets or open capsules.

Anwser: D Rationale: We would not position in the supine position when administer medications because this action has the chance to cause aspiration. We would place our patient in high-Fowler's. Flushing between medications prevents any possible interactions between the medications. To prevent the tube from becoming clogged, all medications should be given in liquid form whenever possible. Medications in extended-release formulations should not be crushed before administration. Give medications separately and flush with water between each drug. Some medications may interact with each other or become less effective if mixed with other drugs. We always want to check with another source to make sure that the medication being given can be crushed.

Which of the following statements regarding ambulation using a walker is true? A. Patient teaching regarding use of a walker can be delegated to nursing assistive personnel (NAP) or to unlicensed assistive personnel (UAP). B. The client's elbows should be flexed about 45 degrees when ambulating with a walker. C. Assisting a patient with ambulation using a walker may be delegated to licensed practical/vocational nurses (LPN/LVNs). D. Using a walker to ambulate eliminates the need for non-slip footwear.

C, TRUE; Assisting a patient with ambulation using a walker may be delegated to licensed practical/vocational nurses (LPN/LVNs). Rationale: A, FALSE; Patient teaching regarding use of a walker CANNOT be delegated to nursing assistive personnel (NAP) or to unlicensed assistive personnel (UAP). (An RN may delegate this task.) B, FALSE; The clients elbows should be flexed at a bout a 30 degree angle not a 45 degree angle. D, FALSE; Walkers do not replace the need for non-slip footwear.

Upon assessing the site and infusion, you notice the patient's IV site has edema, coldness, and pain. What nursing interventions would you consider? Select all that apply. A. Check infusion site every 2-hours for signs and symptoms B. Restart the infusion at a different site C. Rub/massage the affected area D. Discontinue infusion if signs and symptoms continue E. Increase flow rate to ensure that patient is receiving fluid fast enough.

Correct Answer(s): B and D Rationale: Restart the infusion at a different site because you do not want to keep causing continuous irritation. If signs and symptoms keep occurring, you want to discontinue the infusion and inform the provider. You want to check the infusion site every 1-hour if these signs and symptoms occur. NEVER massage or rub the affected area. Do not increase the infusion rate, swap sites and continue at the same rate.

Teaching patient to use an incentive spirometer The nurse is teaching the patient how to use an incentive spirometer when the patient says "I don't understand the purpose of doing this" what would be a correct response from the nurse? a. "using the incentive spirometry can help maximize lung inhalation, supports optimal gas exchange, and can clear and expectorates secretions" b. "using an incentive spirometer is something every patient has to do to help with their breathing" c. "It is a requirement that we teach patients how to use incentive spirometry after surgery, but you don't have to do it" d. "you should talk to a respiratory therapist about your concerns"

Correct Answer: A Rationale: incentive spirometry helps maximize lung inhalation to prevent or reduce atelectasis. It also supports optimal gas exchange and helps clear and expectorate secretions.

Content: Monitoring an IV Site and Infusion The nurse just inserted an IV on the first stick. The nurse comes back in an hour to assess the IV site. Which of the following are complications when assessing the patient's IV site. (Select all that apply). A. Erythema at the access site B. No pain at the site of insertion C. Purulent drainage at the site of insertion D. Streak formation

Correct Answer: A, C, and D Rationale: Monitoring the IV site is very important for the nurse to assess every hour. Erythema, drainage and streaking can all be signs of inflammation and infection. If the IV site is infected this could lead to further complication of the site and also lead to the unsuccessful delivery of medication through the IV.

A nurse is performing wound irrigation with a direct stream of solution. How far away from the wound should the syringe be? a. 3 inches b. 1 inch c. directly on the wound d. none, you do not use a syringe to irrigate a wound

Correct Answer: B Rational: Irrigating at a high pressure can cause discomfort for the patient as well as can damage granulation tissue.

Assisting the patient with Oral care How often should you perform oral hygiene on a patient an hour? a. 1 time an hour b. 1-2 times an hour c. 2 times an hour d. Only when the patient asks

Correct Answer: B Rationale: While A and C also are correct B is the most correct. While 1 time an hour may be acceptable for some patients, others may need up to 2 times an hour. This is important to keep the patient's mouths moist especially for patients not allowed to have fluids by mouth or who cannot drink.

What position should you put the patient in when administering medication via a gastric tube? a. semi-fowlers b. supine c. high-fowlers d. prone

Correct Answer: C Rational: Reduces the risk of aspiration

Content: Extremity Restraints An elderly patient with dementia has hit another patient who is sharing a room with him. The patient has also been trying to get out of bed all morning even though he is a high fall risk. The nurse decides to put wrist restraints on the patient to prevent him from hitting the other patient again and to prevent him from falling out of bed. What should the nurse's next action be? A. Wait until the patient is asleep to take off the restraints. B. Administer chemical restraints to prevent the patient from yelling and threatening the nurses and other patients. C. Notify the primary provider for an order for the restraints within the next hour. D. Notify the family.

Correct Answer: C Rationale: Applying extremity restraints are not an independent nursing action. In this case the restraints were an emergency call by the nurse. As long as the nurse receives an order within the hour for the restraints then the nurse will not be at fault for false imprisonment.

Content: Implementing Alternatives to the Use of Restraints Which of the following would be a correct expected implementation when implementing alternatives to restraints? A. Ask a family member or significant other to stay with the patient. B. increase unnecessary environmental stimulation and noise. C. Make the environment less homelike as possible. D. Do not provide the patient with adequate lighting in he or she room.

Correct answer: A Rationale: Having a family member or significant other to stay with the patient provides companionship and familiarity.

Content: Ambulation with a cane Which of the following actions would indicate to the nurse that the patient needs further teaching on how to ambulate with a cane? A. The patient is holding the cane on his/her stronger side and close to the body B. The patient advances his/her strong leg first after advancing the cane C. The patient advances the cane 4-12 inches first D. The patient advances their weaker foot, parallel to the cane

Correct answer: B Rationale: In order for ambulation with a cane to be safe and effective, the patient needs to advance the cane first on their strong side and then advance their weak foot first using the cane and their strong leg for support. If the patient were to advance their stronger leg first, they would have to put all their weight on their weak side which could lead to a fall.

A client has an enteric infection and the provider has ordered a stool specimen. The client has passed stool. Which of the following would alter the results? A. Stool specimens collected on separate days B.Stool collected after antibiotics are started C. Stool collected from an ostomy device D. Stool collected from an incontinence brief

Correct answer: B Rationale: Therapy with antibiotics before specimen collection may decrease the type and amount of bacteria.

A nurse is caring for a new client in a long-term care facility. At night, the client tends to wander. What should the nurse do? A.Put all four side rails on bed up. B. Give medication to sedate client. C. Provide adequate lighting, such as a night light during sleeping hours. D. Apply a waist restraint

Correct answer: C Rationale: Appropriate lighting can reduce disruptive behavior related to fear in an unfamiliar environment.

Content: Collecting a Stool Specimen for Culture When collecting a stool specimen for a culture, you must do all of the following except? A. Verify the order for the stool specimen in the patient's medical record. B. Identify the patient. C. Do not perform hand hygiene or put on PPE, even if indicated to. D. Collect as much stool as possible to send to the laboratory.

Correct answer: C Rationale: Hand hygiene and PPE prevent the transmission of microorganism. You should always perform hand hygiene; PPE is required based on transmission precautions.

Content: Fecal occult blood test A clinical instructor is observing a nursing student perform a fecal occult blood test. Which of the following actions would alert the instructor she needs to intervene? A. The nursing student obtains a stool sample from the middle of the bowel movement B. The nursing student obtains two stool samples from two different areas of the bowel movement for both windows of the card C. The nursing student puts developer on the samples immediately after applying them to the testing card D. The nursing student interprets a blue color change on the card as a positive result

Correct answer: C Rationale: To allow adequate time for the sample to penetrate the testing paper and dry, the student should wait 3-5 minutes before applying the developer. All the other actions were appropriate for a FOBT.

An 85 year old female patient who is starting therapy post hip surgery has been newly issued a walker. After educating the patient on proper use of the walker, which finding by the nurse demonstrates patient understanding of proper use of the walker? (Select all that apply) A). The patient moves the walker forward 6 to 8 inches then sets it down with all four feet on the floor before stepping the unoperated leg into the center of the walker. B). The patient firmly places their hands on the cross bar of the walker before stepping forward. C). The patient moves the walker forward 6 to 8 inches then sets it down with all four feet on the floor before stepping the operated leg into the center of the walker. D). The patient firmly and equally places their hands on hang grips before stepping forward. E). Patient attempts to ride walker down the stairs.

Correct answers: A & D Reasoning: Having all four feet of the walker on the floor provides a broad base of support. Moving the walker and stepping forward moves the center of gravity toward the walker, ensuring balance and preventing tipping of the walker. Stepping forward with the stronger leg will help with balance as well as reduces pain and chances of injury. Standing within the walker and holding the handgrips firmly provide stability when moving the walker and help ensure safety.

A nurse is preparing to obtain a urinary specimen from an indwelling urinary catheter. While checking the specimen label with the patient identification bracelet the nurse confirms which of the following to be essential information written on the specimen label? (Select all that apply) A). DOB & Room number B). Patient's name & identification number C). Mother's maiden name D). Time & route of collection E). Identification of person obtaining the sample

Correct answers: B, D, & E Rationale: Confirmation of patient identification information ensures the specimen is labeled correctly for the right patient. Confirmation of time and route is important and specific to the type of specimen collection needed. The identification of the person obtaining the specimen is for liability reasons.

When removing a pill from a multi dose bottle, what is the nurse's correct technique? a. using a gloved finger to reach inside the bottle to remove the appropriate dose b. removing the appropriate does and then throwing the multi dose vial away c. do not open the bottle until at the bedside d. pouring the pills into the cap to obtain the correct number, and then pouring the pills into a labeled cup

answer: d Rationale: The nurse should not touch the medication before giving it to the patient. By pouring the medication into the top, the correct dose is able to be obtained without the nurse touching the medication.

Which is not considered an intervention to be included during hourly nurse rounding? A. Make sure patients can reach call light and that their personal needs are met B. Ask the patients if they need to use the bathroom C. Administer ordered medications such as analgesics D. Reposition patients and make sure they are comfortable

Rationale: C. Administer ordered medications is the correct answer. This is not considered an intervention during hourly rounding. Medications are administered as ordered and not necessarily due during hourly rounding. The interventions included in hourly rounding vary, and they include interventions that pertain to pain, personal needs, repositioning, toileting, comfort, and environmental checks.

All of the following are true about graduated compression stockings except: They are used to prevent phlebitis They can be either knee-length or thigh-length The applied pressure promotes venous return to the heart Application is a nursing intervention that does not require an order

Rationale: D. is the correct answer. A provider order is required for use of graduated compression stockings; this is not a nursing intervention. Compression stockings are used to prevent phlebitis, they can be either knee-length or thigh-length, and they do promote venous return to the heart.

Ms. Rodgers is an inpatient on a med-surg floor for injuries related to a fall. She had previous stroke that has left her with some residual weakness on her right side. She ambulates with a walker at home but was instructed to call for assistance when ambulating during her stay because she is a fall risk. What are some ways to decrease her fall risk? (select all that apply) a. Complete hourly rounding. b. Place the majority of the client's belongings around them so they won't have to get up to retrieve them .c. Teach the client how to use the call light and leave it within the clients reach. d. Complete a fall-risk assessment at admission and at regular intervals. e. Place a belt restraint on the client while they are on the toilet to prevent another fall.

a. Correct. Hourly rounding is a good way to limit the chance of falls simply by making sure the client has what they need without having to get up while they are alone. Assessing the 4 P's during hourly rounding ensures that you are present to assist them with "pain, potty/toileting, positioning, and personal belongings." b. Incorrect. Placing too many items around the patient is a fall risk. Keeping the client's room clutter-free is an important part of fall prevention.ATI: Fundamentals for Nursing, Tenth Edition, Chapter 12, Client Safety, p. 59. c. Correct. The client may not understand how to work the call light upon admission. If the call light is not within reach, they won't be able to call when they need assistance ambulating, leading to a greater fall risk.ATI: Fundamentals for Nursing, Tenth Edition, Chapter 12, Client Safety, p. 59 .d. Correct. Completing a fall-risk assessment is a key method for fall prevention. This should be done regularly. ATI: Fundamentals for Nursing, Tenth Edition, Chapter 12, Client Safety, p. 59. e. Incorrect. Restraining the client for fall prevention is a risk for false imprisonment. ATI: Fundamentals for Nursing, Tenth Edition, Chapter 12, Client Safety, p. 63.

After educating the patient on how to adjust the the cane correctly, the nurse assess how well the patient understood the instructions. What findings demonstrate that cane is adjusted correctly by the patient? A. "I will wear slippers because the cane will support me" B. "I will hold my cane in the hand same side of weak or injured leg" C. "To climb stairs, I should advance the stronger leg up first, followed by the cane and weaker leg." D. "I can hold middle of the cane"

answer : C rationale : when patient stair up and down, the patients have to hold the cane with strong side first , and move the cane onto the step with weak legs. If not, the patient will be lost balance.

Content: Administering Medication via a Gastric Tube A nurse is planning to give medications to a client that has a percutaneous endoscopic gastrostomy (PEG). What consideration should ALWAYS be made when giving medications through a gastric tube? SELECT ALL THAT APPLY a. all pills can be crushed and mixed with water or recommended liquid b. all capsules can be opened and mixed with water or recommended liquid c. when giving liquid medications, the amount should be read at eye-level at the meniscus d. if the doctor has ordered multiple medications, it is okay to assume that all the medications can be administered at the same time e. pour 30mL of water into the tube before medication, follow each medication with a 5-10mL flush, follow that last medication with a 30-60mL flush

answer(s): c, e rationale: -Reading the meniscus at eye level is the best way to ensure that the correct amount of liquid medication has been poured up. Flushing between medications prevents any possible interacts between the medications. Flushing at the end maintains tube patency, prevents blockage by medication particles, and ensures all doses enter the stomach. -Only certain pills can capsules can be altered before being administered; long acting or slow release drugs are examples of medications that cannot be crushed. The nurse should always research the medications before giving them to the patient to ensure that the patient has no allergies to the medications or that mixing the medications will have no adverse effect.

1. When applying an extremity restraint, where should you attach the quick-release knot? A. side rail B. bed frame C. IV pole D. wheelchair

answer: B rationale: If the quick release knot is tied to a movable object, the patient might be injured when the side rail is lowered or the object (IV pole or wheelchair) is moved. The frame of the hospital bed is an object that moves with the bed, which prevents injury when transporting patient.

2. Which signs at an IV site would indicate infiltration? A. redness, heat, swelling B. bleeding at the site C. swelling, coolness, pallor D. pus, warmth, pain

answer: C rationale: If an IV is infiltrated, the fluid flows into the tissue, which would cause swelling, coolness, and pallor at the site. Redness, heat and swelling are signs of phlebitis. Bleeding at the site could be a complication of anticoagulant therapy. Pus, warmth, and pain at the site would indicate a local infection of the site.

Content: Restraints 1. A nurse is told by the physician to put extremity restraints on their client. What should the nurse do as they apply these restrains? a. Make sure you can fit 3 fingers between the restrain and the patient's extremity. b. Secure the restraint to the moveable part of the bed. c. Remove the restraints every hour in order to perform range of motion. d. Note the integrity of the skin before applying the restraint.

answer: D Rationale: You should assess the skin prior to applying the restraint to know if the restrain caused any skin damage. When applying restraints you should have 2 fingers between the extremity and the restraint. The restraint should be secured to a part of the bed that does not move to ensure that the patient is not hurt when the moveable part of the bed is moved. The removal of restraints should be every 2 hours.

Content: Monitoring an IV Site and Infusion Redness, swelling, heat, pain, and induration are all signs of what? a. Phlebitis b. Infiltration c. Fluid overload d. Allergic reaction

answer: a Rational: Phlebitis refers to inflammation of a blood vessel at the IV site. Rubor, tumor, calor, and dolor are all cardinal signs of inflammation.

Content: Applying an extremity restraint A nursing instructor is watching the nursing student apply an extremity restraint on a combative patient. Which of the following actions would be a reason for the nursing instructor to intervene. a. The nursing student pads the patient's bony prominences. b. The nursing student ties the restraint to the side rail. c. The nursing student ties a quick release knot. d. The nursing student ensures two fingers can fit between the restraint and the patient's extremity.

answer: b Rational: Securing the restraint to a side rail may injure the patient when the side rail is lowered.

A nurse is examining a 55 year old women who is 4 days postoperative from a mastectomy. Upon assessing the surgical incision, the nurse notices drainage that is thick, a dark yellow in color, and has a foul odor. How would the nurse document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage

answer: b Rationale: Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.

Content: Wound Irrigation The nurse is planning to irrigate the wound with of a patient that is reporting pain. The nurse notes wound does not have approximated edges. What are some proper implications that the nurse should take? a. administer analgesics to the patient before the procedure and use a clean technique b. administer analgesics to the patient before the procedure and use a sterile technique c. tell the patient that the pain should subside once the wound is irrigated and use a clean technique d. administer analgesics to the patient before the procedure and use clean OR sterile technique

answer: b rationale: Pain is a subjective experience; wound care/irrigation may cause pain to the patient that can be relieved by an analgesic. If wound edges are not approximated, sterile technique and solutions should be used to encourage the healing process.

Content: Administering Oral Medications 1.A nurse is preparing to administer an oral medication. The nurse is about to perform her 3 checks of the medication. The nurse knows that the first check is: a. at the patient's bedside b. comparing the medication label to eMAR c. reading the eMAR and selecting the proper medication from the medication supply system d. prescribing the medication

answer: c Rationale: The first check occurs when the nurse reads the eMAR or the medication administration record and removes the appropriate medication from the drawer. This check usually occurs in the medication room and not usually by the bedside.

The order reads: Lanoxin 0.125 mg PO now. In regards to the rights of medication administration, which of the following questions should the nurse ask themselves to ensure that the patient is receiving the medication for the right reason? a. Is the correct dose being administered? b. How is the medication administered? c. Does administration require medication math to calculate the dose? d. Do the patient's condition, symptoms, and health status warrant receiving this medication?

answer: d Rationale: Although answers a, b, and c, are questions that need to be asked to ensure correct administration of medication, these are questions that would confirm the right dose, route, and preparation. The patient's condition, symptoms, and health status are the things that need to be known to ensure this medication is given for the right reason.