Vital Signs
A nurse is preparing to check a patient's apical pulse. Where is the apical pulse located?
Left 5th intercostal space, midclavicular line
What is the most effective way to stop the spread of infection?
Hand hygiene
Where are the 3 places that a nurse should check medications prior to administration?
In the med room
In a quiet place outside the patient's room
At the bedside
What is the correct angle for an IM injection?
90 degrees
A nurse is caring for a patient with an area of intact, non-blanchable erythema on the sacrum. What stage pressure injury will the nurse document?
Stage I
How many liters of oxygen can be delivered by a nasal cannula?
1-6 L/min
A nurse is caring for a patient on aspiration precautions. What actions will the nurse need to take?
Elevate head of bed (90 degrees for oral intake), encourage slow and small sips/bites, remain upright after eating, provide oral hygiene
What are the 10 rights of medication administration?
Patient, medication, dose, route, time, education, refusal, documentation, assessment, evaluation
What are 3 possible sites to administer a subcutaneous injection?
Abdomen, posterior lateral arm, anterior thigh, back, lower loins
A nurse is auscultating a patient's lungs and hears crackles in the lower lobes bilaterally. What might this indicate?
Fluid in the lungs, which may be caused by conditions such as CHF, pneumonia, pulmonary
What does bradypnea mean?
Respiratory rate less than 12 breaths/minute
A nurse is caring for a patient with c-diff. What precautions will the nurse need to implement?
Contact plus precautions. Wash hands with soap and water and clean equipment/surfaces using bleach wipes.
A nurse is caring for a patient who is taking digoxin. What adverse effects should the nurse monitor for?
Bradycardia, nausea/vomiting, weakness, electrolyte abnormalities, confusion, visual disturbances (blurred vision or colored/yellow halos)
A nurse is preparing to administer an IM injection into the vastus lateralis. What anatomical landmarks will be used to locate this site?
Place one hand on the patient's greater trochanter and one hand on the lateral femoral condyle. Visualize a tic-tac-toe board and inject into the outer middle third.
A nurse is preparing to insert an NG tube. How will the nurse measure to determine how far to insert it?
From the tip of the nose to the earlobe to the xiphoid process
A nurse is caring for a patient who begins to experience respiratory distress. What oxygen device can the nurse apply that will deliver the highest concentration of oxygen?
A non-rebreather mask can deliver 10-15 L/min with an FiO2 60-95%
What scale is used to assess a patient's risk for falls?
Morse Fall Scale
A nurse is preparing to administer Lasix to a patient. What should the nurse assess prior to administration? Provide 3 examples.
Blood pressure, lab values (sodium, potassium, creatinine), intake/output, daily weight
What are the appropriate needle gauges for a subcutaneous injection?
25-27 gauge or 28-31 gauge insulin syringe
A nurse is caring for a patient with a chest tube and notes constant bubbling in the water seal chamber. What might this indicate?
An air leak
What is the expected oxygen saturation for a patient with COPD?
88-92%
A nurse is caring for a patient with measles. What precautions will the nurse need to implement?
Airborne precautions. Wear an N-95 mask and place patient in a negative pressure room if available.
A nurse is caring for a patient with a gastric tube who is order for metoprolol succinate (Toprol XL). How will the nurse administer this medication?
Metoprolol succinate (Toprol XL) is an extended release medication and cannot be crushed. The nurse should not administer and notify the provider to obtain an order for an alternative medication.
What is the z-track method and why would it be utilized? Demonstrate how a nurse would perform it.
The z-track method would be used to administer an IM injection in a patient with a large amount of subcutaneous tissue overlying the muscle. The nurse should displace the tissue with the non-dominant hand, administer the injection, withdraw the needle, and release the skin.
What scale is used to assess the risk for pressure injury?
Braden Scale