Legal Dimensions
PPE and Infection Control
Ohh Oxygen
Wound Care
It's all about Urine
Personal Care
Terms
All Mixed Up
100
This term is used to describe the practice in which the nursing assistant may perform tasks
Scope of Practice
100
Which of the following modes are likely to serve as a vehicle for the transmission of Legionella?
A. Touching the belongings of a patient with Legionella
B. Patient aspiration of water particles
C. Direct contact with a patient’s skin
D. Indirect contact transmitted from an improperly cleaned device
B. Legionella requires droplet precautions
100
A nurse teaches a patient how to use an incentive spirometer. Which projected pt outcome will support the conclusion that the use of the incentive spirometer was effective?
A. Supplemental oxygen use will be reduced
B. Inspiratory volume will be increased.
C. Sputum will be expectorated
D. Coughing will be stimulated
B. Inspiratory volume will be increased.
100
This is the medical term used for ulceration on any bony prominence of the body
Pressure Ulcer
100
Urinary Catheters are used to treat urinary incontinence.
True or False?
False
100
The water temperature when giving a bath is between _____________?
110-115 degrees F.
100
This is when a portion of the large bowel is surgically removed, in which the surgeon creates an opening in the abdominal wall, creates a stoma for emptying the bowel.
Colostomy
100
What are the principles of good body mechanics?
Good Body Alignment, Good posture and balance
Wide base of support
Use of muscles in your thighs, hips, shoulders, upper arms
Bend your knees and squat to lift a heavy object
Hold items close to your body and base of support
200
Inserting NG Tube, IV Lines, and administering medications are all tasks performed by a Nursing Assistant? True or false
Fale
200
The best way to prevent the spread of infection is by __________?
Handwashing
200
A primary HCP orders chest physiotherapy with percussion and vibration for a newly admitted pt. Which information obtained by the nurse during the health history should alert the nurse to question the provider's order?
A. Emphysema
B. Osteoporosis
C. Cystic Fibrosis
D. Chronic bronchitis
B. Osteoporosis
200
The nurse is giving a bath to the patient and notices a red area on the sacrum. What is the next action for the nurse to take?
Reposition patient off of their back
200
The medical term for urine with a bloody tinge would be?
Hematuria
Hema= blood
Uria- urine
200
The nurse is performing ROM exercises for the elbow. What exercises are performed?
Flexion and Extension
200
This is surgical procedure of rerouting the excretion of urine from the body when the bladder has been removed due to cancer, and ureters rerouted.
Urostomy
200
A nurse teaches a client how to use an incentive spirometer. Which projected client outcome supports the conclusion that the use of the incentive spirometer was effective?
A. Expiratory volume will be decreased
B. Inspiratory volume will be increased
C. Sputum will be expectorated
D. Coughing will be stimulated
B. an incentive spirometer provides a visual goal for the measurement of inspiration. Sustained inspiration opens airways, increases the inspiratory volume, and reduces the risk of atelectasis.
300
Information regarding the status of a Nursing Assistant's license, any legal issues, are recorded by the state in which they are employed are found in the ___________.
Nursing Registry
300
What articles of equipment are used for PPE?
Gloves
Gown
Mask
Goggles
Bonnet
Shoe protectors
300
A pt has thick tenacious respiratory secretions. Which should the nurse do to liquify the pt's respiratory secretions?
A. Change the pt's position every 2 hours
B. Get a prescription for an antitussive agent
C. Encourage the pt to drink more fluid
D. Teach effective deep breathing
C. Encourage the pt to drink more fluid
300
This stage of the pressure ulcer is reddened, What is this stage?
Stage 1
300
Mrs. Green is complaining of pain with urination. What is the medical term for this condition?
Dysuria
300
The nurse is preparing to bath the patient. What measures can the nurse take to prevent the patient from being burned?
Measure the temperature of the water prior to bathing.
Have the resident check the temperature of the water with their hand.
300
Mr. Smale is having difficulty with breathing due to his Congestive Heart Failure. What position would help to improve his breathing?
Semi Fowler's
300
A nurse hears as client explain the purpose of pursed-lip breathing to a relative. Which information would indicate to the nurse that the client correctly understood the nurse’s teachings about pursed-lip breathing?
A. Precipitates coughing
B. Helps maintain open airways
C. Decreases intrathoracic pressure
D. Facilitates expectoration of mucus
B. Purse-lip breathing is meant to prolong expiration against slightly closed lips, to maintain a positive airway pressure that keeps the airway open for longer.
400
This law was passed to protect one's privacy and confidentiality of medical information?
HIPAA
400
This is a microbe which normally lives on the skin, but can cause havoc when obtains access to another part of the body where it normally does not live.
Opportunistic organism
400
A pt's hemoglobin saturation via pulse oximetry indicates inadequate oxygenation. Which should the nurse do first?
A. Notify the primary HCP
B. Encourage breathing deeply
C. Raise the head of the bed
D. Administer oxygen
C. Raise the head of the bed
400
A client is admitted to the hospital with a partial-thickness skin loss and blister on the sacrum. The nurse should develop a plan of care for which stage of pressure ulcer? Refer to figure. A. Stage I ulcer
B. Stage II ulcer
C. Stage III ulcer
D. Stage IV ulcer
B. A stage II ulcer is characterized by partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A stage I ulcer is characterized by a reddened area and intact skin. Stage III ulcers are full-thickness lesions of the skin. Stage IV ulcers also are full-thickness lesions, with exposed muscle, bone, or supportive tissue.
400
Painful, burning urination and cloudy urine are all symptoms of what medical condition?
U.T.I
Urinary Tract Infection
400
The patient is on a Q2hr turning schedule. He is now lying face towards the ceiling. What is the name of this position?
Supine Position
REMEMBER: sUPine....the UP in the word will make you remember facing towards the ceiling.
400
Giving fluids/nutrients through the GI tract via feeding tube is called
Enteral Nutrition
400
The nurse is looking up her neighbor's medical records using the electronic medical records on the computer. She is not caring for this person. The Supervisor witnessed the nurse viewing the medical records. Can she be terminated and charges brought against her for this action?
Yes, wrongful use of electronic records is punishable by law according to HIPAA regs.
500
Rules & regulations made by administrative agencies in conformity with enacted law; boards of nursing are administrative agencies at the state level
Administrative law
500
Your resident has been diagnosed with Pneumonia. The care plan states he will need to be instructed to do deep breathing and coughing exercises. The nurse knows these should be done:
A. Every day
B. Every 1-2 hours while awake
C. Every 4 hours
D. Twice a Shift
B. Every 1-2 hours while awake
500
A nurse evaluates that the pt understood teaching about the purpose of pursed-lip breathing when the pt includes which information when explaining its purpose to a relative?
A. Precipitates coughing
B. Helps maintain open airways
C. Decreased intrathoracic pressure
D. Facilitates expectoration of mucus
B. Helps maintain open airways
This act prolongs exhalation and maintains positive airway pressure, which maintains an open airway and prevents airway collapse.
500
What stage is a wound which involves the skin, muscle and bone?
A. Deep tissue injury
B. Stage II pressure ulcer
C. Stage III pressure ulcer
D. Stage IV pressure ulcer
D. In a stage IV pressure ulcer, there is full-thickness tissue loss with exposed bone, tendon, or muscle. Eschar or slough may be present in some parts of the wound.
500
The normal color of urine is ?
Clear light yellow
500
The nurse is applying lotion to the patient's back while performing a back massage. When giving a back rub, where do you start?
A. Arms
B. Lower Back
C. Upper Back
B. Lower Back
Stroke upwards from the lower back to the shoulders, down over the upper arms, back up the upper arms, across the shoulders and down to the lower back.
500
When the skin sticks to a surface while muscles slide in the direction the body is moving, damaging underlying blood vessels and skin tissue, is known as ___________?
Shearing
500
This is a condition in which the person is not getting enough oxygen, and is becoming cyanotic, confused. Their pulse oximeter reading is below 90%
Hypoxia
600
A nurse must administer a medication. Which should the nurse do first?
A. Verify the prescription for accuracy.
B. Check the patient's identification armband.
C. Ensure the medication is in the medication cart.
D. Determine the appropriateness of the prescribed medication.
A. Verify the prescription for accuracy.
600
Signs of early Hypoxia include:
Restlessness, dizzy, and disorientation are early signs
600
Which clinical manifestation is of most concern when the nurse assess a pt who has impaired mobility?
A. Shallow respirations
B. Increased oxygen saturation
C. Decreased chest wall expansion
D. Gurgling sounds when breathing
D. Gurgling sounds when breathing
600
A nursing intervention used to prevent the development of pressure ulcers.
Turn and reposition every 2 hours
Good Skin Care
Good Nutrition
Wrinkle Free bed linens
600
The nurse is emptying the urinary drainage bag. She is aware that urine is formed in the ___?
A. Bladder
B. Kidneys
C. Bowels
D. Liver
B. Kidneys
600
Bed safety involves leaving the bed in a raised position
True or False
false
600
The loss of muscle strength and function due to inactivity
Muscle Atrophy
600
Care that involves relieving or reducing the intensity of uncomfortable symptoms with producing a cure is known as ________________?
A. Terminal Care
B. Palliative Care
C. End of Life Care
D. Advanced Directive
B. Palliative Care
700
If you harm a patient by administering a medication (wrong drug, wrong dose, etc) ordered by a physician, which of the following is true?
a. You are not responsible, since you were merely following the doctor's orders.
b. Only you are responsible, since you actually administered the medication.
c. Only the physician is responsible, since he or she actually ordered the drug.
d. Both you and the physician are responsible for your respective actions.
d. Nurses are legally responsible for carrying out the orders of the physician in charge of a patient unless an order would lead a reasonable person to anticipate injury if it were carried out. If the nurse should have anticipated injury and did not, both the prescribing physician and the administering nurse are responsible for the harms to which they contributed.
700
The nurse needs to disinfect her hands after caring for the patient. What is method of disinfecting hands between patients is acceptable?
Alcohol Based Hand Sanitizer.
700
Which are effective leg exercises the nurse should encourage a patient to perform to prevent circulatory complications during the postoperative period?
A. Flexing the knees
B. Isometric exercises
C. Dorsiflexion exercises
D. Passive range of motion
C. Dorsiflexion exercises
700
In the normal aging process, the skin loses elasticity, and oil producing glands diminish production. As a result, the elderly have dry skin. What measures are taken to alleviate this issue?
Baths or shower every other day.
Lotions applied to skin
Use of non irritating soaps, rinse off skin after washing.
Increase oral fluids
700
Urine leaks during exercise, sneezing, coughing, and a sudden urge to void is known as _________________?
Stress Incontinence
700
Mrs. Elliott has a foley catheter. How often is perineal care performed?
A. Bedtime
B. Daily
C. As directed by the care plan
D. When the drainage bag is emptied
C. As Directed by the care plan
700
The medical term for someone who has lost their hair is known as ________________?
Alopecia
700
The patient has been diagnosed with ALS. The nurse knows this disease affects the function of the voluntary muscles. The person's senses remain intact, but their speech is affected. The resident needs to use bathroom. What is the best action of the nurse?
A. Offer the use of a bedside commode
B. Offer the use of a bedpan
C. Offer to walk the patient to the restroom.
B. Offer the resident the bedpan.
The patient has lost the ability to walk, voluntary muscles.
800
A fellow student asks you about your legal liability when you do your clinical practice. Which of the following are true?
(1) Student nurses are responsible for their own acts of negligence if these result in patient injury.
(2) Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse.
(3) A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital.
(4) Nursing instructors may share a student's responsibility for damages in the event of patient injury if the instructor failed to provide reasonable and prudent clinical supervision.
a. (1) and (3)
b. (2) and (4)
c. (1), (2), (3)
d. All of the above
d. All of the answers are true.
800
The nurse's hands became covered in body fluids while taking the trash bag to the dirty utility room. What is the best method to disinfect her hands?
Handwashing with soap and water. Alcohol hand sanitizer is not recommended when hands are soiled with any body fluids.
800
Which should the nurse do first when caring for a nonverbal pt who is restless, agitated, and irritable?
A. Administer oxygen
B. Suction the oropharynx
C. Reduce environmental stimuli
D. Determine patency of the airway
D. Determine patency of the airway
Early signs of hypoxia are restlessness, agitation, and irritability due to low oxygen levels to brain cells. Check your ABCs
800
A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?
A. Milk
B. Oranges
C. Bananas
D. Chicken
B. Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins.
800
Mrs. Smith had a sudden urge to void, and could not get to the toilet in time. This condition is known as
______________.
Urge Incontinence
800
You are to perform ROM exercises after the bath. Which exercises are completed for the ankle?
A. Dorsiflexion
B. Supination
C. Extension
D. Plantar Flexion
A and D
800
This is an age related hearing loss, usually sensorineural.
Presbycusis
800
A nurse completes an Incident Report after a patient falls while getting out of bed unassisted. Which is the purpose of this report?
A. Ensure that all parties have an opportunity to document what happened.
B. Help establish who is responsible for the incident.
C. Make data available for quality-control analysis.
D. Document the incident on the patient's chart.
C. Make data available for quality-control analysis.
Incident Reports help to identify patterns of risk so that corrective action plans can take place.
900
What is the main role of the American Nurses Association?
A. Establish standards for nursing practice.
B. Recognize academic achievement in nursing.
C. Monitor educational institutions granting degrees in nursing.
D. Prepare nurses to become members of the nursing profession
A. Establish standards for nursing practice.
900
A patient presents to the emergency room exhibiting signs of bacterial meningitis. What is the first thing the nurse does in this situation?
A. Obtain vital signs q15 minutes
B. Obtain a patent IV for immediate fluid resuscitation
C. Place the patient in a separate room and initiate droplet precautions
D. Obtain blood cultures and begin a broad-spectrum antibiotic
C. Bacterial Meningitis is a serious and infectious disease process that requires droplet precautions, and cases must be reported to the CDC
900
Which piece of information documented in the clinical record of a male adult should the nurse consider problematic?
A. Simvastatin 20 mg, PO, in the evening
B. Pulse 100 bpm
C. Oxygen saturation 85%
D. WBC 8,000/mm3
C. Oxygen saturation 85%
900
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply.
A. Contact the surgeon.
B. Instruct the client to remain quiet.
C. Prepare the client for wound closure.
D. Document the findings and actions taken.
E. Place a sterile saline dressing and ice packs over the wound.
F. Place the client in a supine position without a pillow under the head.
A,B,C,D. Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low-Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.
900
Mrs. Kelly has bladder control. The call light was not within reach, and she was unable to get to the toilet in time.
This type of incontinence is ____________?
Functional Incontinence
900
Mrs. Irons fell on the ice, and fractured her wrist, and is in a full arm cast. She was admitted to the rehab center. On admission, the nurse notices her fingers are swollen, pale, and numb. What would be the best action of the nurse?
A. Apply Ice
B. Apply heat
C. Take off the cast
D. Notify the provider
D. Notify the provider
900
When brushing a patient’s hair, the nurse identifies white oval particles attached to the hair behind the ears. For which should the nurse assess the patient?
A. Pediculosis
B. Hirsutism
C. Dandruff
D. Scabies
A. Pediculosis is characterized by white oval particles attached to the hair. When identified, the nurse should assess the patient further for the presence of scratch marks on the scalp and by asking the patient if the head feels itchy. Also, the nurse must assess the extent of infestation and if any other areas of the body are infested with other types of lice. A patient with this infestation should be on contact isolation to prevent spread of the infestation to others.
900
The nurse is preparing medications for administration. In addition to the right medication, the nurse adheres to which additional rights of medication administration? Select all that apply.
A. The right dose
B. The right route
C. The right time
D. The right client
E. The right staff member
F. The right documentation
A,B,C,D,F The rights to administering medications include the right medication, the right client, the right dose, the right route, the right time, right documentation, the right reason for the medication, and the right response to the medication.