Stop the Spread!
A nurse removes gloves after caring for a patient and immediately enters another patient's room. Which action was missed?
A. Applying a new gown
B. Performing hand hygiene
C. Changing the patient's linens
D. Documenting the visit
B. Performing hand hygiene
RATIONALE
Gloves do not replace hand hygiene. Cleaning the hands between patients helps break the chain of infection.
A nurse enters a room and notices that the patient's bed is elevated, the call light is on the floor, and the patient is weak. Which action should the nurse take?
A. Lower the bed and place the call light within reach
B. Leave the bed elevated
C. Encourage the patient to get the call light
D. Remove the call light
A. Lower the bed and place the call light within reach
RATIONALE
A low bed and accessible call light are basic fall-prevention measures.
A patient with darker skin reports pain over the heel, but the nurse does not see redness. What should the nurse do?
A. Assume the skin is healthy
B. Assess the heel for temperature and tissue changes
C. Wait until an open wound appears
D. Assess only the other heel
B. Assess the heel for temperature and tissue changes
RATIONALE
Pressure-related changes can be difficult to see in darker skin. Pain, warmth, and changes in firmness may be early warning signs.
A nurse is assessing a wound with a small amount of clear yellow drainage. Which documentation is appropriate?
A. Purulent drainage
B. Sanguineous drainage
C. Serous drainage
D. Thick bloody drainage
C. Serous drainage
RATIONALE
Serous drainage is typically clear or pale yellow and watery. Accurate descriptions help monitor wound healing.
A patient has been incontinent of urine and is resting in a wet brief. What should the nurse do?
A. Provide perineal care and replace the wet brief
B. Wait until the next scheduled assessment
C. Add another brief over the wet one
D. Avoid inspecting the skin
A. Provide perineal care and replace the wet brief
RATIONALE
Prompt cleansing and moisture management help prevent moisture-associated skin damage.
A patient with influenza must leave the room for a diagnostic test. Which action helps prevent transmission?
A. Have the patient wear a surgical mask
B. Have the patient wear sterile gloves
C. Remove all isolation precautions
D. Keep the patient uncovered during transport
A. Have the patient wear a surgical mask
RATIONALE
A mask on the patient helps contain infectious respiratory droplets during transport.
A nurse is about to administer medication when the patient states, 'That isn't my name.' What should the nurse do first?
A. Administer the medication because the room number matches
B. Ask the roommate to confirm the identity
C. Stop and verify the patient's identity using appropriate identifiers
D. Document that the patient refused medication
C. Stop and verify the patient's identity
RATIONALE
An identification discrepancy must be resolved before treatment. The nurse uses at least two reliable identifiers.
An older adult has fragile skin. Which actions help protect skin integrity? Select all that apply.
A. Handle the skin gently
B. Minimize unnecessary friction
C. Pull adhesive tape forcefully from the skin
D. Assess the skin regularly
A, B, and D
RATIONALE
Aging decreases skin strength and elasticity. Gentle handling, reducing friction, and routine assessment help prevent skin tears.
A patient has a wound that has not progressed through the expected healing process. How is this wound classified?
A. Acute wound
B. Chronic wound
C. Clean surgical wound
D. Newly formed laceration
B. Chronic wound
RATIONALE
Chronic wounds are associated with disruption of the normal healing process and may remain unhealed over time.
A patient has limited mobility and poor nutritional intake. Which nursing actions help reduce the risk of skin breakdown? Select all that apply.
A. Assess skin regularly
B. Reposition to relieve pressure
C. Monitor nutritional intake
D. Avoid examining bony prominences
A, B, and C
RATIONALE
Skin assessment, pressure relief, and attention to nutrition address major pressure injury risk factors.
A nurse prepares to use a blood pressure cuff that was just used on another patient. What should the nurse do?
A. Use it immediately if it looks clean
B. Clean and disinfect it according to facility procedure
C. Wipe it with a dry towel
D. Use the same cuff without cleaning when gloves are worn
B. Clean and disinfect it according to facility procedure
RATIONALE
Shared equipment can transmit microorganisms through indirect contact and must be properly cleaned between patients.
A patient with confusion keeps attempting to climb over raised side rails. Which nursing response is most appropriate?
A. Raise all four rails and leave
B. Assess the patient's needs and use less restrictive safety measures
C. Tell the patient to stop moving
D. Assume the rails will prevent injury
B. Assess the patient's needs and use less restrictive safety measures
RATIONALE
Side rails can create additional injury risks when a patient attempts to climb over them. Safety interventions should address the patient's needs.
A bedbound patient has a reddened area over the sacrum that does not blanch. Which nursing action is most appropriate?
A. Relieve pressure from the area
B. Continue positioning the patient directly on the area
C. Massage the reddened skin
D. Wait until the skin opens
A. Relieve pressure from the area
RATIONALE
Nonblanchable discoloration suggests a Stage 1 pressure injury. Relieving pressure helps prevent further damage.
A nurse notes that a wound has increased drainage and a new unpleasant odor. Which action is appropriate?
A. Document the change and assess for infection
B. Ignore the change
C. Stop performing wound assessments
D. Assume the wound is healing normally
A. Document the change and assess for infection
RATIONALE
Changes in wound drainage and odor may indicate complications. Comparing and documenting findings helps identify deterioration.
A nurse observes a new area of nonblanchable discoloration over a patient's heel. What is the most appropriate response?
A. Relieve pressure and document the finding
B. Continue the same positioning
C. Wait until drainage appears
D. Apply friction to the area
A. Relieve pressure and document the finding
RATIONALE
Early recognition, pressure relief, and documentation are important steps in preventing progression of skin injury.
A nurse is setting up a sterile field. Which actions are appropriate? Select all that apply.
A. Inspect the sterile package for tears
B. Keep supplies within the sterile area
C. Consider the outer 1-inch border unsterile
D. Place sterile supplies directly on the outer border
A, B, and C
RATIONALE
A damaged package or contact with an unsterile border can contaminate sterile supplies. Sterile technique helps prevent infection.
A nurse is caring for a patient who is at high risk for falls. Which interventions are appropriate? Select all that apply.
A. Provide nonskid footwear
B. Lock the bed wheels
C. Maintain a clutter-free room
D. Keep the bed elevated between care activities
A, B, and C
RATIONALE
Nonskid footwear, locked bed wheels, and a clear environment reduce fall hazards. The bed should remain in a low position when appropriate.
A nurse is assessing a patient with a Braden Scale score of 9. Which finding would further support concern about pressure injury risk?
A. Independent mobility
B. Adequate food intake
C. Decreased sensation in the lower extremities
D. Ability to reposition without assistance
C. Decreased sensation in the lower extremities
RATIONALE
A low Braden score indicates increased risk. Sensory loss reduces the patient's ability to recognize pressure-related discomfort.
A nurse is caring for a patient with a Jackson-Pratt drain. Which actions help maintain proper drain function? Select all that apply.
A. Check tubing for kinks
B. Empty the drain as indicated
C. Maintain the prescribed suction
D. Leave the drain unsecured
A, B, and C
RATIONALE
Keeping the tubing free of kinks, emptying drainage, and maintaining suction help the drain function properly.
A nurse is caring for a patient with a surgical wound. Which findings should raise concern for a wound complication? Select all that apply.
A. Increasing wound drainage
B. New purulent drainage
C. New unpleasant wound odor
D. Well-approximated wound edges without other concerns
A, B, and C
RATIONALE
Increasing drainage, purulent exudate, and new odor warrant further assessment because they can indicate wound deterioration or infection.
A patient is on contact precautions for C. difficile. Which actions should the nurse take? Select all that apply.
A. Wear gown and gloves for anticipated contact
B. Remove PPE before leaving the room
C. Use alcohol-based sanitizer alone after removing gloves
D. Wash hands with soap and water after glove removal
A, B, and D
RATIONALE
Contact precautions limit contamination, and soap and water are needed to remove C. difficile spores from the hands.
A confused patient repeatedly tries to get out of bed without assistance. Which intervention is most appropriate to consider before restraints?
A. Apply restraints without assessment
B. Use a movement alarm and frequent observation
C. Raise all four side rails to prevent exiting
D. Leave the patient unattended
B. Use a movement alarm and frequent observation
RATIONALE
Movement alarms can alert staff when a patient attempts to get up. They support observation and assistance without immediately restricting movement.
A nurse assesses a patient with a persistent maroon-colored area over the heel. The skin is intact, and the discoloration does not blanch. Which injury should the nurse suspect?
A. Stage 2 pressure injury
B. Deep tissue pressure injury
C. Stage 3 pressure injury
D. Moisture-associated skin damage
B. Deep tissue pressure injury
RATIONALE
Persistent deep red, maroon, or purple nonblanchable discoloration is characteristic of a deep tissue pressure injury, even when the skin is intact.
A pressure injury has full-thickness tissue loss with exposed muscle. Which classification is appropriate?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
D. Stage 4
RATIONALE
Stage 4 injuries involve full-thickness skin and tissue loss with exposed or directly palpable deeper structures such as muscle or bone.
A nurse is caring for four patients. Which finding should receive the most immediate follow-up?
A. A patient with clear, watery wound drainage
B. A patient with intact skin and no pressure-related changes
C. A patient with newly developed purulent wound drainage
D. A patient with a well-approximated surgical incision
C. A patient with newly developed purulent wound drainage
RATIONALE
Purulent drainage indicates a possible wound infection and should be reported. The other findings are not as concerning based on the information provided.