Safety/Infection Control
This type of precaution is used for patients with infections such as influenza or COVID-19 and require the nurse to wear a mask when providing client care.
✅ Answer: What are droplet precautions?
🧠 Rationale: Droplet precautions require wearing a mask when within 3-6 feet of the patient, as well as hand hygiene. Additional PPE, like gowns or gloves, may be required based on hospital policy.
This is the normal range for an adult’s resting heart rate in beats per minute (bpm).
✅ Answer: What is 60-100 bpm?
🧠 Rationale: A normal resting heart rate for adults is 60-100 bpm. A heart rate below 60 bpm (bradycardia) or above 100 bpm (tachycardia) may indicate an underlying condition and should be assessed further.
This mnemonic is commonly used to assess a patient's pain, covering aspects such as onset, location, and intensity.
✅ Answer: What is PQRST?
🧠 Rationale: This mnemonic helps nurses systematically assess pain.
This is the first step a nurse should take before assisting a client with personal hygiene care.
✅ Answer: What is assess the client's ability to perform self-care?
🧠 Rationale: Before providing hygiene care, the nurse should determine the client's level of independence, mobility, cognitive status, and personal preferences to provide individualized care and promote client dignity.
This technique is used during a physical assessment to feel for abnormalities such as swelling, tenderness, or masses.
✅ Answer: What is palpation?
🧠 Rationale: Palpation involves using the hands to feel the body’s surface and underlying structures for abnormalities, such as tenderness, swelling, or masses. It is a key part of a comprehensive physical assessment.
A nurse notices frayed electrical cords in a patient’s room. What is the first action the nurse should take?
✅ Answer: What is remove the device and report it to maintenance?
🧠 Rationale: Frayed electrical cords pose a fire and shock hazard. The nurse should remove the device from use immediately, report it for repair, and ensure patient safety before continuing with care.
When taking a blood pressure reading, the nurse should position the patient’s arm this way to ensure accuracy.
✅ Answer: What is heart level?
🧠 Rationale: Keeping the arm at heart level ensures an accurate blood pressure reading. If the arm is too high, the reading may be falsely low; if it's too low, the reading may be falsely high.
This term describes pain that extends beyond the original site of injury, such as left arm pain in a heart attack.
✅ Answer: What is referred pain?
🧠 Rationale: Referred pain occurs when pain is felt at a site different from the affected organ due to shared nerve pathways. For example, myocardial infarction (heart attack) pain is often felt in the jaw, left arm, or back.
To maintain oral hygiene, unconscious patients should be placed in this position to prevent aspiration.
✅ Answer: What is the side-lying or lateral position?
🧠 Rationale: Placing an unconscious patient on their side with the head slightly lowered allows oral secretions and excess fluids to drain out, reducing the risk of aspiration pneumonia.
This technique involves observing a patient's body language, posture, skin color, and overall appearance during an assessment.
✅ Answer: What is inspection?
🧠 Rationale: Inspection is the visual examination of the body or specific body parts to assess general appearance, posture, skin condition, and any visible abnormalities. It is the first step in a physical assessment.
This link represents someone who is vulnerable to infection due to factors like weakened immunity or chronic illness.
✅ Answer: What is the susceptible host?
🧠 Rationale: A susceptible host is an individual who is vulnerable to infection due to factors like a weakened immune system, chronic illness, age, or poor nutritional status. Protecting this link requires appropriate immunization, health promotion, and infection prevention strategies.
A patient’s respiratory rate is 8 breaths per minute. This medical term describes the condition.
✅ Answer: What is bradypnea?
🧠 Rationale: Bradypnea refers to a respiratory rate below 12 breaths per minute in adults. This can be caused by opioid overdose, neurological issues, or respiratory depression and requires immediate assessment.
This term describes pain that lasts longer than 3 to 6 months and often persists beyond the normal healing process.
✅ Answer: What is chronic pain?
🧠 Rationale: Chronic pain lasts beyond the expected recovery period and can result from conditions like arthritis, neuropathy, or fibromyalgia. It often requires long-term management strategies beyond acute pain treatments.
This is the most important reason for providing perineal care to clients, especially those who are incontinent or have a catheter.
✅ Answer: What is preventing infection and skin breakdown?
🧠 Rationale: Perineal care helps remove bacteria, urine, or feces, reducing the risk of urinary tract infections (UTIs) and skin breakdown, which can lead to pressure ulcers and discomfort.
This type of data is based on what the patient reports or describes, such as pain or feelings of dizziness, and is considered subjective.
✅ Answer: What is subjective data?
🧠 Rationale: Subjective data is information provided by the patient, including their symptoms, feelings, perceptions, and experiences (e.g., "I feel nauseous" or "I have a headache"). This type of data cannot be measured or observed directly by the nurse and relies on the patient's personal experience.
This link in the chain of infection involves how pathogens are transferred from one host to another, including methods like direct contact, airborne transmission, or vectors.
✅ Answer: What is the mode of transmission?
🧠 Rationale: The mode of transmission refers to how the pathogen is spread from one host to another, either via direct contact, droplets, airborne particles, fomites, or vectors like insects. This is critical to understand in order to implement proper isolation and precaution measures.
This method is considered the most accurate for measuring core body temperature.
✅ Answer: What is a rectal temperature?
🧠 Rationale: A rectal temperature provides the most reliable measurement of core body temperature, making it ideal for infants, critically ill patients, and those with hypothermia. However, it is invasive and not routinely used for general screening.
When a non-verbal patient is in pain, the nurse should assess for these behavioral signs of discomfort.
✅ Answer: What are facial grimacing, restlessness, moaning, guarding, and increased vital signs?
🧠 Rationale: Patients who cannot verbalize pain may exhibit non-verbal cues such as grimacing, guarding the affected area, increased heart rate, restlessness, or moaning. Nurses should use specialized pain scales like the PAINAD (Pain Assessment in Advanced Dementia) scale to evaluate pain in non-verbal patients.
When assisting a client with a bed bath, the nurse should begin washing at this area of the body.
✅ Answer: What is the face (specifically the eyes)?
🧠 Rationale: The nurse should begin with the face and eyes using a clean, damp cloth without soap, moving from the inner to the outer corner of the eye to prevent the spread of infection. The cleanest areas should be washed first, followed by progressively dirtier areas to prevent contamination.
Before beginning a physical assessment, the nurse should gather all necessary supplies. This is important to ensure that the nurse can do this during the assessment.
✅ Answer: What is minimizing interruptions?
🧠 Rationale: Gathering all necessary supplies before starting the assessment ensures that the nurse can proceed with the examination efficiently and without interruption. This prevents unnecessary delays and helps maintain patient comfort, reducing the risk of distraction and promoting a more organized and thorough assessment.
The stage of infection, during which the pathogen enters the body and begins to multiply, but the host may not yet exhibit symptoms.
✅ Answer: What is the incubation period?
🧠 Rationale: The incubation period is the time between exposure to the pathogen and the appearance of symptoms. During this stage, the pathogen is multiplying, but the person may not feel sick yet.
This term describes the difference between a patient’s systolic and diastolic blood pressure and is an important indicator of cardiovascular health.
✅ Answer: What is pulse pressure?
🧠 Rationale: Pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure (e.g., 120/80 mmHg → 120 - 80 = 40 mmHg). A narrow (<30 mmHg) or wide (>50 mmHg) pulse pressure can indicate conditions such as shock, heart failure, or arterial stiffness.
This type of pain is caused by nerve damage and is often described as burning, tingling, or shooting pain.
✅ Answer: What is neuropathic pain?
🧠 Rationale: Neuropathic pain results from nerve damage or dysfunction and is commonly seen in conditions like diabetic neuropathy, sciatica, or postherpetic neuralgia. It does not respond well to traditional pain relievers and often requires anticonvulsants or antidepressants for management.
When assisting a client with denture care, the nurse should do this to prevent the dentures from being damaged.
✅ Answer: What is line the sink with a towel or use a basin of water?
🧠 Rationale: When cleaning dentures, it’s important to line the sink with a towel or use a basin of water to cushion the dentures in case they are accidentally dropped. This helps prevent damage or breakage. Additionally, dentures should be cleaned with cool water, a soft brush to avoid any harm, and denture cleaner (not toothpaste).
After completing a physical assessment, it is essential for the nurse to document their findings promptly. This ensures that the assessment is accurate, legible, and useful for continuity of care.
✅ Answer: What is providing a legal record and ensuring continuity of care?
🧠 Rationale: Documenting findings immediately after an assessment ensures accuracy, serves as a legal record of the patient's condition, and provides critical information for other healthcare providers to review. Proper documentation helps maintain continuity of care and supports timely interventions.