Safe & Effective Care Environment
The nurse performing which action after the administration of medication via intermuscular injection demonstrates appropriate knowledge concerning standard precautions.
1. Recaps the needle and discards the syringe in the disposal unit.
2. Breaks the needle and discards it in a regulated disposal container.
3. Discards the uncapped needle and syringe in a labeled cardboard box.
4. Discards the uncap needle and syringe in a labeled, rigid plastic container.
4. Rationale: Used needles are not recapped. They are disposed of in a labeled impermeable container.
The nurse is assisting in performing a neurovascular check on a client. Which is the best method to use when checking a client's pupillary response to light.
1. Turn the light on directly in front of the eye and watch for a response.
2. Ask the client to follow the light throigh the six cardinal positions of gaze.
3. Check the pupil size and then have the patient alternate between watching the light and the examiner's finger.
4. Instruct the client to look straight ahead and then shine the light on the client, moving it from the temporal area to the eye.
4. Rationale: This is the correct procedure.
Challenge a classmate from an opposite team to do the following:
Be the first to obtain the respiration rate of a manikin.
Do not start until instructor give the go ahead.
Tell the instructor your value.
To ensure client safety, which is the most important for the nurse to assess before advancing a client from liquid to solid food?
1. Bowel sounds
2. Chewing ability
3. Current appetite
4. Food preference
2. Rationale: The consistency of food would be altered depending on the patient's ability to chew or swallow.
A primary health care provider (HCP) prescribes acetaminophen liquid 450 mg orally every 4 hours as needed for pain. The medication label reads 160mg/5mL. The nurse prepares how many mL to administer 1 dose? (Round to the nearest whole number.)
14 mL per dose
Upon entering the room, the nurse finds an older client attempting to use a pillow to put out the flames on a bedspread. Which action would the nurse take first to safely manage this situation?
1. Pull the nearest fire alarm.
2. Close the door of the room.
3. Remove the client from the room.
4. Run to get the nearest fire extinguisher.
3. Rationale: RACE. Remove the patient/victim. Activate the alarm. Contain the fire. Extinguish as needed.
The nurse is ausculating the breath sounds of a client. Which technique, if used by the nurse, would indicate a need for further teaching in the use of a stethoscope?
1. Using the bell of the stethoscope.
2. Asking the client to sit up.
3. Placing the stethoscope directly on the client's skin.
4. Having the client breathe slowly and deeply through the mouth.
1. The bell of the stethoscope is not used, its the diaphragm.
Challenge a classmate from an opposite team to do the following:
Be the first to obtain the apical heart rate from the manikin.
Do not start until instructor give the go ahead.
Tell the instructor your value.
The nurse is collecting data on the respiratory system of a patient being treated for an asthma attack. The nurse determines that the patient's respiratory status is worsening based on which finding?
1. Loud wheezing
2. Wheezing on expiration
3. Noticeably diminished breath sounds
4. Increased displays of emotional apprehension
3. Rationale: diminished breath sounds are an indication of severe obstruction and impending respiratory failure.
The provider prescribes 250 mg of amikacin sulfate every 12 hours. It is available 100 mg/2 mL. How many mL would the nurse prepare to administer in 1 dose?
5 mL per dose
The nurse determines that if an assistive personnel (AP) performs which action during a routine hand-washing procedure, additional instruction is needed in performing appropriate hand-hygiene?
1. Keeps the hands lower than the elbows.
2. Uses 3-5 mL of soap from the dispenser.
3. Washes continually for 15 at least seconds.
4. Dries the hands down from the forearms down to the fingers.
4. Rationale: 1-3 is correct. Drying is from the fingers to the forearm.
The nurse is teaching a client with acute kidney injury to include high-quality proteins in the diet. The nurse educates the client to avoid which food item because it is a low quality protein source?
1. Fish
2. Eggs
3. Chicken
4. Brocolli
4. Rationale: low quality proteins are derived from plant sources and include vegetables and foods made from grains.
Challenge a classmate from an opposite team to do the following:
Be the first to apply PPE for contact isolation.
Do not start until instructor give the go ahead.
Requires: 1. Hand hygience 2. Don gloves. 3. Apply gown. (According to the CDC)
The nurse is caring for a patient disagnosed with a stroke is planning care to maintain nutritional status. The nurse is concerned about the patient's swallowing ability. Which food item would the nurse eliminate from the patient's diet?
1. Spinach
2. Custard
3. Scrambled eggs
4. Mashed potatoes
1. Rationale: Raw vegetables are excluded from the diet of patient's with swallowing difficulties.
The provider orders Ampicillin 18mg/kg IM q 8hrs. The client weighs 91 kg. How many mg will the nurse administer for one dose?
1638 mg
The nurse determines that the assistive personnel (AP) ambulating a client with right-sided weakness is performing the procedure safely when the AP's position is where?
1. Behind the client.
2. In front of the client.
3. On the left side of the client.
4. To the right side of the client.
4. Rationale: On the affected side for support.
The nurse is reinforcing instructions with a client with a cast about how to perform the 3-point gait with crutches. Which instruction would the nurse provide to the client?
1. Move both the cruthches forward and the swing both feet forward to the crutches.
2. Move the right foot, the left crutch, the left crutch, then the right foot forward.
3. Advance the right crutch and the left foot forward, and then bring the right foot and left crutch forward.
4. Simultaneously move both crutches and the affected leg foreward, and then move the unaffected leg forward.
4. Rationale: 1 is a swing through. 3 & 4 is a 4-point gait.
Challenge a classmate from an opposite team to do the following:
Be the first to apply sterile gloves correctly.
Do not start until instructor give the go ahead.
Show the instructor.
The nurse is providing care to a patient who has just experience a liver biopsy performed at bedside. Which position would the nurse place the patient in after the procedure.
1. Supine with the head elevated on one pillow
2. Semi-fowlers with the two pillows under the legs
3. Left-side lying with the pillow under the procedure site
4. Right-side lying with a folded towel under the procedure site
4. Rationale: The liver is on the right side. Place small pillow or folded towel under the puncture site for 2 hours.
The HCP orders metformin (Glucophage) 175 mg PO TID. How many mg will the nurse administer in 36 hours? (Round to the nearest whole number.)
788 mg
The nurse is evaluating a client's safe use of a cane for left sided weakness. What action by the client requires further teaching by the nurse?
1. Holding the cane on the right side.
2. Moving the cane when the right leg is moved.
3. Leaning on the cane when the right leg swings through.
4. Keeping the cane 6 inches out to the side of the right foot.
2. Rationale: 1,3,4 are correct. The cane (placed on strong side) is moved with the opposite leg (weak leg).
The nurse is giving a client with hypertension general information about acceptable foods to include on a sodium restricted diet. The nurse tells the client that which item is lowest in sodium content?
1. Potatoes
2. Instant rice
3. Frozen bread dough
4. Commerical stuffing
1. Rationale: Commercially prepared food is preserved with sodium.
Challenge a classmate from an opposite team to do the following:
Be the first to correctly draw up 10 units of Lantus.
Do not start until instructor give the go ahead.
Bring the filled syringe and medicaiton vial to the instructor.
A cleint has a prescription to receive an enema before bowel surgery. The nurse assists the patient into which best position to administer the enema?
1. Prone
2. Supine
3. Lateral recumbent
4. Lithotomy
3. Rationale: The lateral recumbent position exposes the rectal area and allows the enema solution to flow by gravity in the natural direction of the colon.
The NP has ordered furosemide (Lasix) 40 mg IV daily. The safe dose range for furosemide is 0.25 -1 mg/kg/dose. The patient weights 176 lbs. Calculate the safe dose range and determine if the dose is safe to administer. (Round to the nearest whole number.)
Low: 20 mg
High: 80 mg
Safe