Infection Control
What is the most effective way to prevent the spread of infection?
A: Hand hygiene (washing with soap and water or using alcohol-based rub).
What is the normal range for an adult heart rate?
A: 60 to 100 beats per minute.
How often must a nurse check a patient who is physically restrained, and how often must the restraints be completely removed for skin care and ROM? /
A: Check every 15 minutes; remove/assess every 2 hours.
What federal law protects the privacy and security of a patient's health information?
A: HIPAA (Health Insurance Portability and Accountability Act).
During which phase of the nursing process does the nurse gather subjective and objective data about the patient?
A: Assessment.
What specific personal protective equipment (PPE) must a nurse wear when caring for a patient on Airborne Precautions for tuberculosis?
A: An N95 respirator (or HEPA mask).
If a blood pressure cuff is too small or wrapped too loosely on a patient's arm, how will the reading be affected?
A: It will yield a falsely high reading.
To maintain proper body mechanics when lifting a heavy object or transferring a patient, where should the nurse keep their center of gravity?
A: Low, by bending at the knees and hips (not the waist).
A patient states, "My pain is a 7 out of 10." What type of data is this?
A: Subjective data.
What does the "S.M.A.R.T." acronym stand for when developing patient outcomes during the Planning phase?
A: Specific, Measurable, Achievable, Realistic, Time-bound.
In what order should a nurse remove (doff) PPE after leaving an isolation room?
A: Gloves, goggles/face shield, gown, and mask/respirator.
What is the priority nursing action if a patient's radial pulse is irregular? /
A: Assess the apical pulse for one full minute.
What patient position involves lowering the head of the bed and elevating the foot of the bed, often used for severe hypotension or shock?
A: Trendelenburg position.
What documentation error is committed if a nurse charts a medication or assessment before it actually takes place?
A: Falsification of records (or pre-charting).
A nurse changes a patient's surgical dressing as ordered. Which step of the nursing process is being performed?
A: Implementation.
Which hand hygiene method is mandatory when caring for a patient with a Clostridioides difficile (C. diff) infection?
A: Washing with soap and water (alcohol-based rubs do not kill C. diff spores).
What type of respirations are characterized by alternating periods of deep, rapid breathing followed by periods of apnea, often seen near the end of life?
A: Cheyne-Stokes respirations.
In the event of a hospital fire, what does the acronym "R.A.C.E." stand for?
A: Rescue, Alarm, Confine, Extinguish.
If a nurse performs a procedure on a competent patient who has explicitly refused it, what legal tort could the nurse be charged with?
A: Battery.
Q: What is the purpose of the Evaluation phase of the nursing process?
A: To determine if the patient outcomes/goals were met, partially met, or not met, and to revise the care plan if needed.
What term describes an infection that a patient acquires while receiving treatment in a healthcare facility?
A: Healthcare-Associated Infection (HAI) or Nosocomial infection.
A patient's blood pressure drops significantly when they move from a lying down to a standing position. What is the clinical term for this?
A: Orthostatic (or postural) hypotension.
When using the "P.A.S.S." acronym to operate a fire extinguisher, what are the four sequential steps?
A: Pull the pin, Aim at the base of the fire, Squeeze the handle, Sweep from side to side.
What is the primary legal responsibility of the nurse when a patient is signing an informed consent form for surgery?
A: Witnessing the patient's signature (and verifying they are competent to sign).
Unlike a medical diagnosis which focuses on the disease process, a nursing diagnosis focuses on what?
A: The patient's human response to health conditions or life processes.