Health Assessment NSI
According to the morse fall scale if the patient has fallen during the present hospital admission or if there was an immediate history of physiologic falls, such as from seizures or an impaired gait prior to admission the patient is automatically scored what number? What number is needed for a high risk score?
25, 45
Which HCP has the most exposure to biohazard waste? a. Nurses/NA b. Doctors c. Respiratory therapists d. Physical therapists
A Nurses and NA's make up over 70% of all medical waste
What is a hospital intervention patients can use while in bed to prevent DVTs? A. Bariatric bed B. Pull Bar C. Intermittent pressure cuffs D. Pulse Ox machine
C is the correct answer. IPCs are sleeves that help pump the calves to circulate the blood instead of pooling in the legs. A pull bar, bariatric bed and pulse ox machine will not help with DVTs.
Anything that carries enough of a pathogen or virulence to infect another is called.. a. Radiation waste b. Medical waste c. Hazardous waste d. Infectious waste
D infectious waste
Nurses are the largest health care provider group available for preparedness, response, and recovery in a disaster. A. True B. False
True Rationale: Nurses make up the largest group in the healthcare system and so they are the largest health care group provider during a disaster.
What is the major microorganism causing PLABSI? A.Staph. Aureus B.Klebsiella Pneumoniae C.C. Diff D.E. Coli
A Staph Aureus Rationale: Studies have shown that Staph. Aureus is one of the major causes of PLABSI. Other answers are not correct.
How often should you assess peripheral IV sites to prevent the onset of a bloodstream infection? A.1 hour B.6 hours C.8 hours D.Once a shift
A 1 hour Rationale: Checks should be done in order to check for proper placement and patency and assess the site for the presence of erythema, edema, pain, tenderness, or other abnormalities.
Unused Medication blister packs are considered... a. Infectious waste b. Hazardous waste c. Normal trash d. Recyclable.
B hazardous waste
Which method can prevent infection and complication rates associated with PLABSI (Peripheral Line-Associated A. Blood Stream Infection ) B. Patient gets sufficient sleep C. Diet high in vegetables D. Continuous education E. Monitoring every 48 hours
C The lack of a continuous education program leads to relaxation of the norm, abandonment of good clinical practices and increase in infection and complication rates.
Which two organisms usually cause VAP? a. Gram negative staph b. Gram positive E.coli c. Gram positive staph d. Gram negative E. coli
C & D Rationale: staph bacilli is only gram positive bacilli and it's a common causative bacteria & 60% of causative organism for VAP are gram negative including E. coli
Which is the CLABSI (A central line-associated bloodstream infection) 's manifestations? A. Nausea B. Vomiting C. Pain in the abdomen D. Fever and chills
D Rationale: Clinical manifestations are fever and chills which are the most common.
A nurse is entering a room in Airborne Precautions. Which of the following is the correct order for them to don the appropriate PPE? A. Mask, eyewear, clean gloves, gown B. Eyewear, mask, hair protection, gloves C. Gown, mask, eyewear, clean gloves D. Mask, gown, eyewear, clean gloves
C; Gown, mask, eyewear, clean gloves Answer choice C is the proper PPE to wear into a room with airborne precautions
Does VAP or CAP have a higher incidence rate?
CAP Rational: Community-aquired pneumonia has an incidence rate of 77& while venilator-aquired pneumonia has an incidence rate of only 2.5-40%
A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids.
D Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse should stop the infusion and remove the catheter.
The WHO proposed a multimodal strategy which includes five elements call the "Five Moments for Hand Hygiene" as evidenced based approach to prevent hospital acquired infections. The Five Moments include: (All that applies) A. Before touching the patient B. Before performing the patient C. After exposure / risk of body fluid D. After touching the patient E. After touching the patient surroundings
A, B, C, D, E Rationale: Before touching the patient Before performing the patient After exposure / risk of body fluid After touching the patient After touching the patient surroundings
The nurse is reviewing the 5 Point Bundle Evidence Based Practice. Of the practices below, which statement illustrates understanding? select all that apply a. Hand washing with soap and water b. Sterile insertion with full barrier precautions (cap, mask, sterile gown, sterile gloves, and full sterile drape c. Use of 2% chlorhexidine solution with proper air drying before insertion d. Use of femoral site for catherization e. Prompt removal of unnecessary catheters
A, B, C, E Rationale: Femoral catheters should be avoided, due to their higher risk of infections and thrombotic complications.
Does VAP or CAP have a higher mortality rate?
VAP Rational: While CAP has an incidence rate of 77% the mortality rate is only 6%. VAP has a lower incidence rate of 2.5-40%, but a mortality rate of 13-25.2%
List 5 universal fall precautions.
a. Bed in lowest position b. Side rails up c. Nonskid slippers d. Call light in reach e. Hourly rounding f. Gait belt use g. Fall risk sign h. Fall risk bracelet i. Alert color code j. Care planning
Nursing burnout and exhaustion are associated with: (select all that apply) A. Patient falls B. Medication errors C. Pressure ulcers D. Development of type 2 diabetes E. Accidental death
A, B, C, E Rationale: Nursing burnout and exhaustion are associated with adverse events such as patient falls, medication errors, pressure ulcers, or accidental death because the nurse is not able to deliver high quality care. Development of type 2 diabetes is not associated with nursing burnout and exhaustion.
Preventive measures for restraints include: Select all the apply A. Having a companion/sitter stay with the patient B. Completing a fall risk assessment C. Placing the patient in a room far from the nurse's station D. Utilizing a bed alarm
A, B, D Preventative measures include having a companion/sitter, completing a fall risk assessment and using a bed alarm.
How long after intubation does VAP occur? A. After 6 hours B. After 10 hours C. After 48 hours D. It does not occur after intubation
C Rational: VAP occurs more than 48 hours after intubation. 6 and 10 hours are too soon after intubation. VAP occurs after intubation so D is incorrect
T/F: A fall is defined by an unplanned decent to the floor with injury only.
False
The number way to prevent the spread of diseases including with catheter care is _______ 1)Using disinfecting tips 2)Hand washing 3)Using nitrile gloves 4) Reusing IV tubing
#2 Hand hygiene is a great way to prevent infections. However, studies show that on average, healthcare providers clean their hands less than half of the times they should. This contributes to the spread of healthcare-associated infections that affect 1 in 31 hospital patients on any given day
The World Health Organization has proposed a multimodal strategy, "the Five Moments for hand hygiene" to prevent hospital acquired infections. Which of the following are not a part of the strategy? a. Before touching the patient b. After performing any clean/aseptic procedures c. After exposure/ risk of body fluid d. After touching the patient e. After touching the patient surroundings
B Rationale: You would wash your hands before performing any clean/aseptic procedure
Which of the following are nursing interventions that can help prevent pressure ulcers? Select all that apply. A. Regular skin assessments B. Pressure-redistribution devices C. Adequate hydration and nutrition D. Position changes every 4 hours
A, B, C Rationale: Regular skin assessments, pressure-redistribution devices, and adequate hydration and nutrition are all nursing interventions that can help to prevent pressure ulcers. Position changes should be every 1-2 hours to be effective.
In relation to the nursing process, what symptoms can a nurse assess for when trying to prevent a CAUTI? (Select all that apply) a. Assessing for patency of the catheter. b. Assess the patient's urine odor and color. c. Assess for rashes or lumps around the perineal area. d. Assess for correct catheter placement.
A, B, D. RATIONALE: For answer A, assessing the patency of the catheter is important so we can possibly find any blockages. For answer B, assessing the patient's urine odor and color can be an indication of whether bacteria have invaded the urinary tract. Answer C is not correct because it is a symptom related to diagnosing STIs. Answer D is an important assessment because the incorrect placement of a catheter can increase the chances of allowing the bacteria to enter the patient's body and it can cause further infections in the urethra, bladder, and even in the kidneys.
A charge nurse reviewing needle stick injuries on the unit knows that the implementation of which evidence-based practices can decrease the risk of future incidences? Select all that apply. A) Placing sharps containers within arm's reach of the hospital bed. B) Immediately discarding sharps after use. C) Re-capping needles prior to placing in the sharp's container. D) Emptying sharps containers once they are completely full. E) Installing larger sharps containers in each patient room. F) Training staff on proper waste management procedures.
A, B, E, F Rationale: Evidence-based practices that help to reduce the risk of needle stick injuries include placing sharps containers within arm's reach of hospital beds, exam tables, or bedside chairs; immediately discarding sharps after use; installing large sharps containers which serve as a visual reminder for proper and immediate sharps disposal; and educating staff on proper waste management procedures. Re-capping needles increases the risk of needle stick injuries, and healthcare facilities/nursing leaders should adopt non-recapping policies. Nursing staff should monitor the fullness of sharps containers and empty or replace them once they become two-thirds full.
When San Francisco mandated a maximum of 1:4 ratio of Rn to patients, this led to? (select all that apply) a. Overall demeanor of the RN staff b. Increase in the number of call offs by RN staff c. Lower RN staff sickness d. Decrease cost to the facility related to RN onboarding e. Increase cost to the facility related to RN onboarding
A, C, D Rationale: In a study conducted of RNs in hospitals in San Francisco it showed the ratio of 1:4 decreased the level of stress the RNs were experiencing, leading to increased overall satisfaction with their job. This has led to less turnover which decreases the cost to the hospital for onboarding new nurses, overall a happier staff, and less sickness reported believed to be correlated to the decrease stress experienced by the RNs.
Which is not true for CLABSI (A central line-associated bloodstream infection)? A. Most cases of CLABSI are PREVENTABLE B. Important to maintain clean technique C. Continuous surveillance is necessary D. Leads to prolonged hospital stays
B Rationale: Important to maintain sterile technique
When a nurse patient ratio is greater than 1:4, each 1 patient added to the nurse's shift has a 7% increase of? a. Patient satisfaction b. Hospital mortality c. Nursing care d. Decrease in medical errors
B A study conducted showed that on average the increase in nursing ratios (above 1:4) leads to a decrease in patient care. This is believed to correlate to the increase workload decrease the amount of time and care the RN can give to each patient. This decrease is said to be related to increased infections, bedsores, pneumonia, cardiac arrest, and accidental death.
Which statement from a patient with a high fall risk score indicates the need for further teaching? A. "I should ring my call bell if I want to get out of the bed and wait for assistance." B. "I can wear my slippers from home to walk around the room." C. "I should leave my fall risk bracelet on." D. "My bed should be in the lowest position with the side rails up."
B All the other answers are things we would want a high fall risk patient to do to prevent falls. Slippers from home are not suggested as they may increase the risk of tripping or slipping and then lead to a fall. Non-skid hospital socks are recommended.
A patient with a Morse fall score of 35 would be considered ______ fall risk. A. Low risk B. Moderate risk C. High risk D. No risk
B Moderate fall risk is a score between 25-45, low fall risk is a score of less than 25 and a high fall risk is a score greater than 45
Nursing staff on a hospital unit are reviewing rates of hospital-acquired infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for HAI in patients admitted to the hospital? A. Encouraging adequate oral fluid intake B. Testing urine with a dipstick daily for nitrites C. Avoiding unnecessary urinary catheterizations D. Providing frequent perineal hygiene to patients
C Because catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use.
How much water should you pack in a disaster kit? A. One 16 oz bottle per person B. A 12 pack of bottled water for a week C. One gallon per person per day D. You can get water from your sump pump
C Rationale: One 16 oz bottle per person will not be enough to last more than a few hours. A 12 pack might be ok, but only for a few days; not a week. Your sump pump doesn't provide water, it pumps it out. One gallon, per person, per day will be enough to keep each person hydrated and use for sanitation.
Of the following, which is NOT commonly associated with leading to a catheter-associated UTI? A. Sterility breaks while inserting the catheter B. Backward flow of urine in the catheter tubing C. BID catheter cleaning D. Bowel movements
C. Twice daily catheter care is essential for your patient to reduce the risk of a CAUTI. All of the other answer choices, can lead to the development of a CAUTI.
A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? A. Do you need something for pain right now? B. Please stop yelling. I brough dinner as soon as I could. C. I suggest that you get control of yourself. D. You seem upset. I have time to talk if you would like.
D "You seem upset. I have time to talk if you would like." is the correct answer. Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk.
The nurse assesses an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first? A. Palpate over the suprapubic area. B. Inspect for abdominal distention. C. Question the patient about hematuria. D. Invite the patient to use the bathroom.
D Before beginning the assessment of an older patient with a UTI and on diuretics, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract from the patientsability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible.
A high nursing turnover rate is associated with: a. Increased job satisfaction b. Increased patient satisfaction c. Increased quality of care d. Increased occurrence of adverse events
D Rationale: A high nursing turnover rate may lead to an increase in the occurrence of adverse events such as patient falls, medication errors, pressure ulcers, pneumonia, and/or accidental death. It may lead to the nurses working more hours with more patients at once, which can contribute to job dissatisfaction, decreased quality of care, and negatively impact a patient's satisfaction level and perception.
There are five levels of falls, which level requires a patient to have surgery, casting, traction, or a neuro consult? a) Moderate b) Minor c) Death d) Major e) No injury
D Rationale: A major fall requires a patient to have surgery, casting, traction, or a neuro consult. Moderate fall needs suturing, splinting, or skin glue. Minor fall needs ice, elevation and a dressing. A fall that leads to death is because of a major injury where death results. No injury requires no intervention.
When should neonates or pediatric patients be assessed when having a peripheral IV? a. Every 24 hours b. Every shift change c. Every 15 minutes d. Every hour
D Rationale: Neonates and pediatric patients should be routinely assessed for PLABSI on a 1 hour basis. Every 24, every shift change and every 15 minutes are not appropriate time frames to check peripheral IVs for neonates and pediatric patients.
What is not considered an intervention for patients that are prone to DVTs? A. Doing leg exercises while sitting B. Using compression stockings C. Taking the prescribed anticoagulants D. Eating a high fat diet
D is the correct answer. You do not want the patient to increase cholesterol levels leading to a higher chance of deposits and clotting in their blood. Leg exercises and compression stockings will help circulate blood throughout the body and the anticoagulants can help certain patients avoid clotting issues.
Which of the following is not a part of the 5 steps of disaster preparedness? A. Prevention B. Mitigation C. Preparedness D. Response E. Recovery F. Diagnosis
F) Diagnosis Rationale: The 5 steps of disaster preparedness are: Prevention, Mitigation, Preparedness, Response, and Recovery. Diagnosis is not a part of the 5 steps of disaster preparedness.
True of false, PLABSI is most commonly defined as central line associated blood stream infection
False Rationale: PLABSI is most commonly defined as peripheral line associated blood stream infection
Most nurses have a high understanding of restraints? True or False
F It has been found that most nurses only have a moderate understanding of restraints and that teaching needs to be incorporated into healthcare facilities.
What type of PPE is the least amount of coverage? A. Type A B. Type B C. Type C D. Type D
It is type D Rationale: Type D is usual work clothes while type A is completely encapsulated suits, the ones in-between have some coverage but not as much as A and not as little as D.
TRUE OR FALSE: Is the increased risk for CAUTI directly related to the prolonged use of catheterization?
TRUE RATIONALE: This is true because a CAUTI occurs when bacteria enter the urinary tract through the urinary catheter which causes the infection. The prolonged use of a catheter will increase the chances of that bacteria to enter the urinary tract. And long term use of catheters will require further hospitalization. Therefore, nurses always learn that we should not use catheterization for a long-term use unless absolutely necessary and that catheterization is the last resort.
A physical restraint is a. The use of bodily holds b. Four-point restraints c. Chemical restraint d. Bed rails
a. the use of bodily holds Rationale: Physical restraints require nurses to be proficient in the use of bodily holds and techniques (Bailey et al., 2021). Four-point restraints and bed rails are mechanical restraints. A chemical restraint is any drug that is used (Burke, 2021).
Which of the following is not true about disposing of PPE? a. dispose in special laundry containers b. dispose in specifically marked bags for cytotoxic PPE c. dispose in a trash can d. dispose in special waste containers
c, dispose in a trash can Rationale: You should not dispose of the PPE in a normal trash can because someone else could touch that and be exposed to anything that you were protecting yourself from. All of the other options are correct for disposal of PPE.
True or False: Ventilator associated pneumonia is very preventable.
True. When following evidence-based practices VAP is easily preventable. The top 5 practices include: minimizing ventilator exposure, providing excellent oral hygiene care, coordinating care for subglottic suctioning, maintaining optimal positioning while encouraging mobility, and ensuring adequate staffing.
Which nursing intervention would NOT be considered a Tier 2 intervention for CAUTI prevention? A. Regularly conduct checkoffs on RNs on appropriate catheter insertion techniques. B. Track data and analyze patterns in CAUTI occurrences. C. Only provide information about developing CAUTIs to nurses when needed. D. Involve all members of the healthcare team for CAUTI prevention.
c. Only provide information about developing CAUTIs to nurses when needed. Rationale: Tier 2 interventions for CAUTI prevention includes open and active communication with the nursing team about any CAUTIs to assist the nurse in better patient care, not only limiting communication to when needed. The other answers are all correct Tier 2 interventions.
A standardized assessment tool such as STOPDVTs could a. increase quality of patient outcomes b. decrease quality of patient outcomes c. cause more pulmonary embolisms d. increase patient costs
a Rationale- standardizing hospital procedures and assessment tools can increase effiiciency and patient outcomes by increasing detection rates and prevention.
Preventative measure in the use of restraints include: (select all that apply) a. Fall risk assessment b. Bed alarms c. Room near the nurse's station d. Keeping the patient's door closed e. Frequent monitoring
a, b, c, e Rationale: Fall risk assessment, bed alarms, having the patient's room near the nurse's station, and frequent monitoring are all preventative measure that can be implemented in order to avoid the use of restraints as much as possible. Keeping the patient's door closed is not considered to be a preventative measure, considering the patient needs to be under frequent monitoring, it would not be a good measure to keep their door closed.
Which of the following is a behavioral preventative measure? a. Stress management/relaxation b. Monitoring vitals c. Assessment for fall risk d. Encouraging triggers
a. stress management/relaxation Rationale: Stress management, behavior management techniques, behavior modification techniques, and positive and negative reinforcement are all behavioral preventative measures. Avoiding triggers, no encouraging, is also a behavioral preventative measure. Monitoring vitals and assessment for fall risk are basic preventative measures.
A DVT can _____ a. only occur once then you are immune b. occur more frequently after the first incidence c. occur most commonly in children d. cause vision problems as the first sign and symptom
b rationale: Risk for DVT is not high in children, and there is no immunity (it is not a pathogen). Risk for future DVT increases after an incident, and signs and symptoms to check for include: palor, swelling, pain, etc. NOT immediate vision problems.
A patient reports to their nurse that they are experiencing the following symptoms. Which symptom is NOT associated with CAUTIs? A. Urinary frequency B. Bradycardia C. Lower abdominal pain D. Tachycardia
b. Bradycardia Rationale: The patient that is at risk for a CAUTI will likely be experiencing urinary frequency, lower abdominal pain, and tachycardia. It is unlikely that the patient will be experiencing bradycardia, but rather will be tachycardic.
A DVT may lead to a. pulmonary embolism b. long term health issues c. death, in severe cases d. all the above
d rationale: DVT clots can brek off from the vein in the lower leg and travel through the blood stream to the lungs previnting blood from reaching them. This can be fatal and one third to one half of people with a DVT will have long-term complications caused by damage in the valves.
What are two common clinical manifestations for a patient who has CLABSI?
fever, chills, pain and or discharge at insertion site are all possible answers Rationale: CLABSI is defined as a laboratory-confirmed bloodstream infection not related to an infection at another site that develops within 48 hours of central line placement
A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? A. Provide a calm location for the family to cope and discuss needs. B. Call the hospital chaplain to stay with the family and pray for the deceased. C. Do not allow visiting of the victims until the bodies are prepared. D. Provide privacy for law enforcement to interview the family.
A "provide a calm location for the family to cope and discuss needs" is the correct answer. The nurse should first provide emotional support by encouraging relaxation, listening to the family's needs, and offering choices when appropriate and possible to give some personal control back to individuals.
What are two types of injuries or infection that can contribute to VAP? a. Injured tracheal wall & infected nasopharynx b. Arm & lower leg pain c. Headache & chills d. Infected tonsils & inflamed tongue
A Rationale: An injured tracheal wall, or an injured/infected nasopharynx are the most common injuries that are associated with VAP.
A student nurse is caring for a patient who was recently diagnosed with CLABSI. The nurse needs to intervene when she sees the student nurse do which of the following? a. Leave the catheter hub open after cleaning to go get supplies to change the patients brief b. Flushes heparin in catheter c. Change's dressing over site based on facility protocol d. Follow the insertion and adherence checklist step by step
A Rationale: The student nurse should use a proper securement device whenever they step away from the patient, it should not be left open under any means. The other options are correct and are proper nursing interventions when caring for a patient diagnosed with CLABSI
A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? A. Perform a bladder scan. B. Encourage increased oral fluid intake. B. Assist the patient to ambulate to the bathroom. C. Insert a straight catheter as indicated on the PRN order.
A The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Because of the risk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.
A nurse is asked to present on programs to implement in their nursing homes that will reduce the instance of CAUTIs in residents. Select all the programs that will assist with this goal: A. Creating a program that tracks patient information who have a CAUTI B. Supervising nurses one time for proper aseptic technique with catheter insertion C. Developing an infection specialist team to meet regularly D. Implementing an educational program focused on aseptic technique and CAUTI rates for nurses.
A, C, D Rationale: Answers a, c, and d are all programs that should be implemented within nursing homes to assist with lowering CAUTI rates. Answer b would be correct if the answer stated to "regularly" monitor nurses for aseptic technique, but because the answer states to only supervise one time, the answer is incorrect. All nurses regardless of experience should be regularly monitored.
Experts observed causes for nurse dissatisfaction in their position and general fatigue attributed to? (Select all that apply) a. mismanagement of personnel and resources b. increase patient care c. lack of follow through d. stretched personal requirements e. less call offs
A, C, D Rationale: As the burnout increases with RN's it is correlated with decrease in patient care, lack of feeling supported, and the need to work harder and with a higher stress load. That is what concerned to be the reason that RNs will have: the mismanagement of resources, by being stretched too thin to do their job they will rely heavily on others to pick up part of the workload lack of follow through related to the inability to have the time or the ability to make sure that follow up occurs stretched personal requirements: when the RNs are unhappy at work and having to stay over their shift or come in on days off, it will have a direct impact on their life outside of work
Which of the following are score categories for the Braden scale? Select all that apply. A. Nutrition B. History of Pressure Ulcers C. Sensory Perception D. Mobility E. Activity F. Moisture G. Friction & Shear
A, C, D, E, F, G Rationale: The six Braden scale score categories include sensory perception, activity, nutrition, moisture, mobility, and friction & shear. History of pressure ulcers is not a factor of the Braden Scale.
The nurse understands that risk factors for developing a DVT include (select all that apply): A. Pregnancy B. Short periods of travel C. Oral contraceptives D. Smoking E. Prolonged immobility
A, C, D, E. These factors increase the risk of developing a DVT as they contribute to venous stasis and increased coagulability.
Which of the following are ways to prevent falls in the hospital setting? (select all that apply) a) Bed in lowest position b) Rounding every 4 hours c) Fall risk bracelet d) Side rails down e) Individualized care planning
A, C, E Rationale: Ways to prevent falls are bed in the lowest position, side rails up, bed alarm on, nonskid slippers and socks, call light within reach, hourly rounding, use of a gait belt, fall alert sign on the door, fall alert color-coded bracelet, and individualized care planning. Rounding every 4 hours and side rails down are not correct.
The nurse knows that the following patients are at highest risk for developing CAUTI: (Select all that apply) a. Females b. Older adults c. Diabetics and Immunocompromised patients d. Patients with breast cancer
A,B,C RATIONALE: Answers A, B, and C are all referring to populations that are particularly at a higher risk for developing CAUTIs. Females are at a higher risk because they have a shorter urethra. Older adults (both men and women) are at a higher risk for developing CAUTI because they have more problems emptying their bladder completely as they age. Because of that issue, the bacteria have a higher chance of developing in the urinary tract. Diabetics are at higher risk for developing CAUTIS because they suffer from high blood sugar levels and that can weaken the immune system. And immunocompromised patients have a similar problem as diabetics. Because of their suppressed immune systems, they are at a higher risk for developing CAUTIs. The population referred in answer D is not related to this question.
Which of the following are essential items in a disaster kit? Select all that apply A. Water B. Food C. Whistle D. First aid kit E. Hairspray F. Lip balm
A,B,C,D Water, food, a whistle and a first aid kit are essential items in a disaster kit. Hair spray and lip balm are accessories and not essential items to include in a disaster kit
What should peripheral IV catheter sites be assessed for? Select all that apply. a. Swelling b. Tenderness c. Drainage d. Redness e. Poikilothermia
ABCD Rationale: Peripheral IV catheter sites should be assessed for paresthesia, redness, tenderness, swelling and drainage. Poikilothermia would not be a manifestations for PLABSI.
What is PLABSI? (Select all that apply) A.The presence of a peripheral line without a CVC with the presence of phlebitis B.The resolution of clinical symptoms after withdrawal of the peripheral line C.The presence of CVC without an alternative source of infection D.With the exclusion of an alternative explanation for bacteremia
ABD Rationale: PLABSI is the presence of a peripheral line without a central venous catheter (CVC) and at least one of the following: the presence of phlebitis or resolution of clinical symptoms after withdrawal of the peripheral line, with careful exclusion of an alternative explanation for bacteremia.
Where are the 3 most common places people keep their disaster kits? Select All That Apply A. Home B. In-laws C. Car D. Work
ACD Rationale: Your home, your car, and your work are the places you are most often and are most likely to be if a disaster occurs. Your in-laws should have their own disaster kit.
Which of the following sites is the preferred site for catherization? a. Internal Jugular Vein b. Subclavian Vein c. Femoral Vein d. All of the above, as there is no preferred site.
B Rationale: All of the sites listed are options to use for central venous catheter. The subclavian vein is the preferred site for sole purpose of reducing CLABSI. The subclavian vein has been identified as being less infection prone compared to the other site.
The nurse is caring for a patient who has a central line, which of the following does the nurse know to be true? a. CLABSI are not preventable, and it is just something that happens in the hospital setting b. A CLABSI usually develops within 48 hours of central line placement c. CLABSI does not cost the hospital any burden d. There is no need for continuing education for a nurse after they have identified what a CLABSI is and how to prevent it
B Rationale: CLABSI usually develops within 48 hours of placement, CLABSI is preventable if using proper placement and continued care. Each facility should have continuing education set in place not only for CLABSI but other preventable disease. CLABSI usually costs the hospital around $46,000 per case
A GEM nursing student is assisting an OB nurse in cleaning up the delivery room following a complicated birth. The student demonstrates adequate understanding of medical waste disposal and infection control practices when they state that drapes used to soak up blood and body fluids should be discarded where? A) Trash can in the utility room. B) Red biohazard bag. C) Green organic waste bag. D) Blue dirty linen bag.
B Rationale: Infectious waste should only be discarded into red biohazard bags which are specially made to contain medical or biohazardous waste. All other answers are incorrect.
A patient tells the nurse they are going on a road trip for 10 hours to a vacation. What will the nurse educate to the patient beforehand regarding DVT prevention? A. Drive straight through to the destination B. Get out of the car every 2 hours to stretch and move C. Sit crossed legged D. Lessen water intake
B is the correct answer. Moving every 2 hours will ensure blood is not pooling in their legs while traveling. Driving a total of 10 hours straight through will increase chances of a clot forming by being still for that long of a time. Sitting crossed legged can cause the same issues. Lessening water intake can cause the patient to be dehydrated, leading to thicker blood that can clot easily.
Which of the following is NOT considered a form of PPE? A. Gloves B. Raised Toilet Seat C. Mask D. Shoes
B, Raised Toilet Seat PPE is the special equipment that creates a barrier, separating you from germs o Reduces chances of touching, being exposed to, and spreading germs.
Which is not a reason why there has been a shortage of PPE due to COVID-19 in the United States? a. dysfunctional budget b. high global supply c. federal government failed to distribute domestic inventories d. sudden major demand
B, high global supply Rationale: This would be incorrect because there was actually a low global supply and a major disruption between the supply and the communication. The other options are all reasons as to why there was a shortage of PPE in the United States.
A patient being treated in the hospital for 2 weeks and has developed a CAUTI. What is the best response to your patient to describe this condition? a. A urethral infection caused by care with soap and water after a patient voids b. An infection, typically caused by bacteria or fungi entering into the patient urinary tract c. A lung disease that has been acquired in the hospital d. The most common signs and symptoms of a CAUTI are upper abdominal pain and vomiting. I don't believe you have this condition
B. A CAUTI is an infection typically caused by bacteria or fungi entering into the patients urinary tract, and moving into the bladder. You want to cleanse the urethral area of the foley insertion site with soap and water, as taught by your healthcare instructors.
The home health nurse is providing education on how to prevent pressure ulcers for a bedridden patient. Which of the following indicated further teaching is indicated? a. Lift the client when turning to prevent sliding b. Change the client's position every 4 hours c. Do not massage directly on reddened areas d. Completely dry the client after a bath to help prevent moisture in bed
B. Change the client's position every 4 hours Rationale: The patient's position should be changed every 1-2 hours to help prevent constant pressure on any one spot. The longer a patient remains in one position, the more likely they are to develop a pressure injury. The client should be lifted to prevent sliding. The nurse should not massage any reddened areas directly and the client needs to be fully dried before being placed in bed to prevent moisture buildup.
A patient presents with pain, tenderness, erythema, and an increased circumference of the left calf. What does the nurse suspect? A. Pulmonary embolism B. Deep Venous Thrombosis C. Post-thrombotic Syndrome D. Peripheral Venous Disease
B. Clinical manifestations of a symptomatic DVT include pain, minimal swelling, increased calf circumference, tenderness, and erythema. A patient may also have an asymptomatic DVT.
A step-down patient is in need of a blood transfusion due to a low hemoglobin of 7. The nurse is about to prepare for the transfusion. What actions should the nurse take when giving a transfusion? (Select all that apply) a. Stay with the patient for 45 mins once the transfusion begins. b. Ask another nurse to verify the blood transfusion. c. Have the UAP hang the blood and prime the tubing. d. Stop the transfusion if the patient is febrile. e. Stay with the patient for 15 mins once the transfusion begins.
B. D. & E. Rationale: All three are actions the nurse should take when implementing a blood transfusion. The UAP should never prime any kind of IV tubing and monitoring the patient for 45 minutes is not priority since the first 15 minutes is the window of time most adverse effects of transfusions occur.
Extensive radiation therapy is prescribed to a patient on the med surge unit. The nurse knows that they should take certain precautions when providing care to the patient after treatment. What is the nurse's priority action? a. Wash hands going into and out of the patient's room. b. Limit amount of time within the room. c. Done PPE prior to entering the room. d. Have the UAP sit with the patient for comfort.
B. Limit amount of time within the room. Rationale: It is imperative that all healthcare workers practice ALARA (as low as reasonable achievable) when working with patients going through Radiation Therapy. Washing hands before going into and out of the room is great but does not address full body radiation exposure. PPE is not sufficient in protecting anyone from radiation exposure, only lead vests can. The UAP should not be sitting in the room with the patient since they will be exposed by high levels of radiation.
Which of the following statements made by the patient at risk for a DVT indicates a need for further teaching? A. "I will take my anticoagulant as prescribed." B. "I do not need to get out of bed today because I have on my IPCs." C. "I should change my position frequently." D. "I should increase my fluid intake."
B. While IPC use is important in DVT prophylaxis, early ambulation and remaining active is also important. Therefore, the nurse should educate the patient on the importance of ambulation in combination with the use of IPCs and anticoagulation therapy.
What does the hospital acquired infection VAP stand for? A. Ventricle-Atrial Polarization B. Ventilator Associated Pneumonia C. Virulence Associated Prognosis D. Vestibular Awareness Problem
B: Ventilator Associated Pneumonia VAP stands for Ventilator Associated Pneumonia. The other options are not correct.
What types of medications are considered high risk to contribute to falls? A. Diuretics B. Antidepressants C. Analgesics D. Vitamins
C Diuretics are considered low risk, antidepressants are considered medium risk, and analgesics are considered high risk. Vitamins have no fall risk score.
What is the most significant way to reduce the possibility of infection when inserting a PVC? A. Tell the patient to pray B. Use a washcloth to wipe the area of insertion C. Wash your hands with soap before procedure D. No way to prevent bacteremia
C Hand Hygiene is the single most effective precaution for prevention of infection transmission between patients and staff.
Reducing the chance of an emergency from happening is which step in the disaster preparedness plan? A. Response B. Prevention C. Mitigation D. Preparedness
C Mitigation is the correct answer. Prevention is stopping an incident from occurring. Preparedness are activities that increase a communities ability to respond when a disaster occurs. Response are actions carried out immediately before, during, and immediately after a hazard impact.
Which of the following patients is the MOST at risk for developing a pressure ulcer? A. 45-year-old man with a 30-pack year smoking history and a Braden score of 22. B. 65-year-old women with hypertension and a Braden score of 19. C. 70-year-old women with diabetes and a Braden score of 8. D. 60-year-old man with recent CVA and a Braden score of 10.
C Rationale: A Braden scale sore of less than 9 is a severe risk for pressure ulcers. 19-23 is no risk, 15-18 is mild risk, 13-14 is a moderate risk and 10-12 is a high risk.
Which of the following is NOT a predictor of job satisfaction? A. Supportive leadership B. Advancement opportunities C. High nurse-to-patient ratios D. Good interprofessional communication
C Rationale: A high nurse-to-patio ratio greater than 1:4 is associated with higher mortality rates in patients. In San Francisco, a ratio of 1:4 or less led to better demeanor of nurses, less burnout, lower levels of staff sickness, and lower staff turnover.
What is the best tool to decide if a patient is at risk for falls? a) Glasgow Coma Scale b) Braden Scale c) Morse fall Scale d) CAGE questionnaire
C Rationale: Morse fall scale is used to identify fall risk patients. The Glasgow coma scale is used to describe the level of consciousness of a patient following a brain injury. The Braden Scale is used to predict pressure ulcer risk. The CAGE questionnaire is used for alcohol use and abuse.
What occurs with the WBC with a patient that is diagnosed with VAP? a. WBC stays the same b. WBC decreases c. WBC increases d. WBC should not be measured in a VAP patient
C Rationale: because there is an infection (pneumonia) the patient's WBC will increase
When should nurses utilize restraints? A. When the patient doesn't stay in bed B. When they feel like it C. When all other holistic measures have been exhausted D. All of the above
C Restraints should only be used when all other holistic measures have been used and have failed.
What is the most commonly reported hospital-acquired condition(s), leading to over 500,000 cases per year? a. Tuberculosis b. Pneumonia c. Catheter-Associated UTI d. DVT/PE
C. Although pneumonia and tuberculosis are common infections that are reported in the hospital, catheter associated urinary tract infections are among almost 50% of all infections acquired in the hospital setting. DVT's and PE's are common after surgical procedures, and you should reposition, use compressions and ambulate with your patient to reduce the risk.
The nurse is caring for a patient with very limited sensory perception who is often moist, on bedrest and has very limited mobility. She rarely eats half of her meals and needs maximum assistance with moving. The nurse knows that her Braden scale score reveals that she is a. At a low risk for a pressure injury b. At moderate risk for a pressure injury c. At high risk for a pressure injury d. The Braden Scale wasn't indicated and doesn't need done
C. At high risk for a pressure injury Rationale: A severe risk is a score of 6-9, high risk is a score of 10-12, moderate risk is a score of 12-14, mild risk is a score of 15-18, and no risk is a score at 19 and above. The score from this patient's assessment equals 10 which reveals a high-risk score. Her score was calculated as follows: Sensory perception (2-very limited), moisture (2-often moist), activity (1-bedfast), mobility (2-very limited), nutrition (2- probably inadequate), and friction & shear (1- problem). The Braden Scale should be done on each patient.
The nurse is taking care of a patient with MRSA. The patient askes for a bed bath at night to help them go to sleep. What is the priority action for the nurse? a. Ask the HCP for melatonin. b. Have the UAP wash the patient at night. c. Post signage for standard precautions. d. Administer pain medication to relax the patient.
C. Post signage for standard precautions. Rationale: Notifying all healthcare workers and/or visitors of the patient's level of precautions will prevent further spread of the infection. Using PPE with MRSA patients is very important to protect the patient along with protecting the workers. A and B are plausible answers but are not priority. D is incorrect since the patient did not mention anything about pain.
It is recommended to change IV tubing every ________ hours to help prevent PLABSI A. 24 B. 36 C. 72 D. 96
D 96 hours In many hospital settings, IV tubing is changed frequently for fear of a site being infected. Although this an understandable assumption, in most instances, patients are not at increased risk of infection if their IV is in for 96 hours rather than 72 hours. Patients with intermittent rather than continuous infusions can have their IVs changed more frequently—every 24 hours. However, if the tubing is contaminated or infected, then tubing should be changed immediately
How often should you check your kit to replace expired food or add/remove items based on changing family needs? A. Every 3 months B. Every 3 years C. Every time you need an oil change D. Every Year
D Rationale: Every 3 months is excessive; most food would not be expired. It would be okay to add or remove items as needed but every 3 months is not necessary. Every 3 years would mean most of the food is expired, many extra items may no longer be needed, or items that are needed are not in the kit (diapers, dog food). Every time you need an oil change is not a consistent measure of time among everyone. Every year is the suggested amount of time to check your kit. Most foods would be ready to be exchanged and family needs may only very slightly.
Which of the following is NOT a precaution sign? A. Droplet Precautions B. Airborne Precautions C. Standard Precautions D. Sterile Precautions
D, Sterile Precautions All of the other options are typical hospital precautions.
The nurse is assigned four patients. Which patient is at the highest risk for pressure ulcers? a. A 4-year-old admitted with the flu b. An ambulatory 88-year-old admitted for shingles c. An active 40-year-old admitted with a broken arm from a basketball game fall d. A bedridden 72-year-old admitted with a UTI with incontinence
D. A 72-year-old admitted with a UTI with incontinence Rationale: The 72-year-old has constant moisture and is immobile and remains in bed. The others are more mobile, less moist, and have less risk factors for a pressure injury giving the 72-year-old the highest Braden Scale score and therefore the high risk for pressure injury.
What is the most common setting that ventilator associated pneumonia occurs? A. Psychiatric Floor B. Nursing Homes C. Home Setting D. Intensive Care Unit
D: Intensive Care Unit The most common setting for VAP is the intensive care unit. This is because of the high rate of mechanically intubated patients. The other settings do not have a high rate of intubations.
