Safety First
How many forms of verification should the nurse use to identify a client?
What are two identifiers?
A client has redness, warmth, pain, swelling, and drainage confined to an incision. Which type of infection does the nurse suspect?
What is a local infection?
A nurse is caring for a client with MRSA. Which PPE should the nurse wear when providing direct care?
What are gown and gloves?
A client receiving IV vancomycin requires monitoring because this medication can damage which organ?
What are the kidneys?
Prolonged immobility causes muscles to become smaller and weaker. What is this called?
What is atrophy?
A nurse almost administers medication to the wrong client but catches the error before administration. How is this event classified?
What is a near miss?
A client begins experiencing malaise, low-grade fever, body aches, and decreased appetite following exposure to an infection. Which stage of infection is the client experiencing?
What is the prodromal stage?
A client with influenza must leave the room for diagnostic testing. What should the nurse place on the client during transport?
What is a surgical mask?
A client taking ciprofloxacin should be taught to report sudden pain involving which body structure?
What is a tendon?
A client has been on bed rest for several days. Before having the client stand for the first time, what should the nurse have the client do?
What is dangle/sit at the bedside?
During ISBARR communication, where should the nurse report significant assessment findings, vital signs, laboratory results, and diagnostic findings?
What is Assessment?
A client's culture identifies a bacterial organism. Which additional test determines the antimicrobial most effective against that organism?
What is sensitivity testing?
A client has tuberculosis. Which room and respiratory protection are required?
What is a negative pressure room and N95?
A nurse is teaching a client prescribed metronidazole. Which substance should the client avoid during treatment and for 48 hr afterward?
What is alcohol?
An immobile client develops shallow breathing and collapse of small sections of the lung. Which complication has occurred?
What is atelectasis?
A client suddenly develops chest pain, decreased oxygen saturation, and altered mental status. Which team should the nurse activate?
What is the Rapid Response Team (RRT)?
A nurse assesses a client with a suspected infection. The client has a RR of 24/min, new confusion, and a systolic BP of 94 mmHg. Which type of infection would you suspect they have?
What is sepsis?
A nurse removes PPE after caring for a client. Place the PPE removal sequence in the correct order:
Gloves → _____ → _____ → _____ → hand hygiene
What are goggles → gown → mask?
A client receiving IV vancomycin develops flushing, itching, and a rash during the infusion. Which factor should the nurse suspect?
What is vancomycin being infused too rapidly?
A nurse assesses an immobile client's lower extremities. Which finding is most concerning for DVT?
A. Bilateral muscle weakness
B. Unilateral edema
C. Decreased ROM
D. Foot drop
What is B — unilateral edema?
The nurse is caring for four clients. Which client should the nurse assess first?
A. An immobile client who has not had a bowel movement in 2 days
B. A client with arthritis reporting increased stiffness
C. A postoperative client with sudden confusion, hypotension, and tachypnea
D. A client with muscle atrophy who needs assistance ambulating
What is C — the postoperative client with sudden confusion, hypotension, and tachypnea?
A client has been ill with an infection for several days. The nurse notes that the client's manifestations are becoming less severe and the number of infectious organisms is decreasing. Which stage of infection is the client experiencing?
A. Incubation
B. Prodromal
C. Decline
D. Convalescence
What is C — Decline?
A nurse removes gloves after caring for a client who has C. difficile. The nurse's hands are not visibly soiled. Which action should the nurse take next?
What is wash the hands with soap and water?
A nurse is reviewing prescriptions for four clients. Which prescription should cause the nurse the greatest concern?
A. Metronidazole for an anaerobic infection
B. TMP-SMX for a client with a sulfa allergy
C. IV vancomycin for MRSA
D. Ciprofloxacin for a UTI
What is B — TMP-SMX for a client with a sulfa allergy?
A client becomes dizzy when standing. BP decreases from 128/76 mmHg lying down to 106/64 mmHg standing within 3 minutes. Which complication should the nurse identify?
hat is orthostatic hypotension?