This organism requires soap and water hand hygiene instead of alcohol gel.
What is C-diff?
RATIONALE:
Alcohol gel is ineffective against C-diff spores. Soap and water physically remove spores from the hands.
Before any transfer, these must always be locked.
What are wheelchair brakes?
RATIONALE:
Unlocked brakes can cause patient falls during transfers.
These should remain wrinkle-free to reduce skin breakdown.
What are bed linens?
RATIONALE:
Wrinkles increase pressure and friction on the skin.
Charting only measurable and observable facts is called this type of documentation.
What is objective documentation?
RATIONALE:
Objective charting improves accuracy and legal defensibility.
This position places the patient flat on their back.
What is supine position?
RATIONALE:
Supine is commonly used for assessments and procedures.
This is the LAST item removed when doffing PPE.
What is the mask or respirator?
RATIONALE:
The mask is removed last to protect the airway from contamination during PPE removal.
This transfer device should be applied at the patient’s waist to assist with standing and ambulation.
What is a gait belt?
RATIONALE:
Gait belts improve safety and reduce caregiver injury risk.
This direction should always be used during perineal care.
What is front to back?
RATIONALE:
Front-to-back cleansing reduces infection risk.
A patient states, “I feel dizzy.” This type of data is documented as this.
What is subjective data?
RATIONALE:
Subjective data comes directly from the patient’s report.
This position is often used to improve breathing and eating.
What is Fowler’s position?
RATIONALE:
Elevating the head of bed improves lung expansion and swallowing safety.
A patient with active pulmonary tuberculosis requires this type of room.
What is a negative-pressure room?
RATIONALE:
Negative-pressure rooms prevent airborne organisms from escaping into surrounding areas.
A patient suddenly becomes weak during transfer. This is the FIRST action.
What is assisting the patient safely to the nearest surface or chair?
RATIONALE:
Patient safety comes before completing the transfer.
While giving a bed bath, you notice redness over the coccyx that does not blanch. This may indicate this.
What is a pressure injury?
RATIONALE:
Non-blanchable redness may be the first stage of pressure injury development.
This communication tool is used in communication between healthcare providers.
Hint: commonly used when a nurse is calling a provider
What is SBAR?
RATIONALE:
SBAR improves organized communication between healthcare providers.
These areas are most at risk for pressure injuries.
What are bony prominences?
RATIONALE:
Pressure over bony areas decreases circulation and damages tissue.
A student exits a contact precaution room still wearing contaminated gloves to grab extra supplies from the hallway. What should the student have done first?
What is remove contaminated gloves and perform hand hygiene before leaving the room?
Contaminated PPE should never be worn into clean hallway areas because it spreads microorganisms to the environment and increases infection transmission risk.
This body mechanics mistake most commonly causes nurse back injuries.
What is twisting while lifting or transferring?
RATIONALE:
Twisting under load places major stress on the spine.
This should NEVER be done with soiled linens because it spreads microorganisms into the air.
What is shaking linens?
RATIONALE:
Shaking linens aerosolizes pathogens and increases infection risk.
A student obtains a blood pressure of 82/48 during morning care and is unsure if the reading is accurate. The BEST action is this.
What is recheck the blood pressure and immediately notify the instructor and assigned nurse?
Abnormal vital signs must always be verified and reported promptly because they may indicate patient instability or deterioration.
Patients should generally be repositioned at least this often.
What is every 2 hours?
RATIONALE:
Frequent repositioning reduces prolonged pressure and skin breakdown.
You enter a room wearing gown, gloves, face shield, and surgical mask. The patient likely has this type of precautions.
Hint: More than one type.
What are droplet plus contact precautions?
RATIONALE:
Some respiratory illnesses require multiple forms of protection because of combined transmission risks.
A post-stroke patient suddenly leans heavily to one side during ambulation. The student should do this FIRST.
What is stabilize the patient and call for assistance?
RATIONALE:
Sudden weakness or imbalance may indicate neurological decline or instability.
During hygiene care, the patient becomes short of breath and fatigued. The student should do this.
What is stop the activity and assess/report the patient condition?
RATIONALE:
Activity intolerance may indicate respiratory or cardiovascular compromise.
A student notices a patient becoming newly confused and difficult to arouse during care but decides to “watch them for a little while” before telling the nurse. This is what the student should do instead.
What is report abnormal findings immediately?
RATIONALE:
Sudden confusion and decreased responsiveness may indicate serious patient deterioration. Delaying reporting can place the patient at significant risk and violates safe nursing practice expectations.
This should be done BEFORE leaving the room as a part of purposeful rounding and fall prevention.
What is place the call light within reach and reassess patient comfort and safety?
RATIONALE:
Accessibility and safety are part of purposeful rounding and fall prevention.