Nursing Process
ADPIE is the step by step clinical layout of the nursing process, it consists of?
Assessment, Diagnosis, Planning, Implement, Evaluation
When should the nurse intiate their last medication check?
A. At patient's bedside
B. Outside the patient's room
C. After documenting
At patient's bedside
When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will flow properly?
Hang the piggyback medication higher than the primary fluid
Hand Hygiene
96.8 o - 100.4 o
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need?
A. Elimination
B. Security
C. Safety
D. Belonging
Elimination
According to Maslow, elimination is a first-level or physiological need. Security and safety are second-level needs, and belonging is a third-level need.
What is the preferred method for Intramuscular (IM) injection?
Ventrogluteal
Which of the following technique(s) is/are for minimizing a patient’s risk for injury when inserting a venous access device? (SELECT ALL THAT APPLIES)
A. Inserting the needle with bevel down.
B. Holding the skin taut directly below the site.
C. Using a vein the dorsal surface of the arm.
B. Holding the skin taut directly below the site.
C. Using a vein the dorsal surface of the arm.
BEVEL UP!!
For Airborne Precautions, is a regular or N95 mask worn?
N95 Mask
Thick, yellow, green, tan, or brown Drainage
Purulent
Which statement is an appropriately written short-term goal?
a. Patient will walk to the bathroom independently without falling within 2 days after surgery.
b. Nurse will watch patient demonstrate proper insulin injection technique each morning.
c. Patient's spouse will express satisfaction with patient's progress before discharge.
d. Patient's incision will be well approximated each time it is assessed by
A. Patient will walk to the bathroom independently without falling within 2 days after surgery.
What route produces the most rapid absorption rate? Vice versa, what route is produces the slowest onset action but more prolonged effects?
Intravenous is the most rapid because it is injected directly into the vein. Oral is the slowest onset action but more prolonged.effects
What is the characteristics of Infiltration at a site?
Swelling and Leaking
Infiltration is when an IV becomes dislodged or vein ruptures, which causes fluid to enter around subcutaneous tissue.
A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?
A. The client had an appendectomy 6 months ago.
B. The client has bipolar disorder.
C. The client is a male.
D. The client is 71 years old.
D. The client is 71 years old.
which of the following actions by the nurse comply with core principles of surgical asepsis? select all that apply.
1. set up sterile field before patient and other staff come to the operating suite
2. Keep sterile field in view at all times
3. Consider the outer 2.5 cm (1 in) of the sterile field as contaminated
4. Only health care personnel within the sterile field must wear personal protective equipment
5. The sterile gown must be put on before the surgical
2- Keep sterile field in view at all times
3- Consider the outer 2.5 cm (1 in) of the sterile field as contaminated
What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery?
a. Consult the surgeon to see if the clinical pathway is being followed.
b. Discontinue the plan of care, because the patient has met the established goal.
c. Monitor patient urine output to evaluate the need for the current plan of care.
d. Notify the patient that the goal has been attained and no further intervention is needed.
c. Monitor patient urine output to evaluate the need for the current plan of care.
How should Insulin be administered when two vials (Regular and NPH) are used?
Regular then NPH (clear then cloudy)
The physician asks the nurse to monitor the fluid volume status of a cirrhosis patient and dehydrated patient. Which is the most effective nurse intervention for monitoring both these patients?
A). Assess the patients for edema in extremities
B). Ask the patients to record their intake and output
C). weigh the patients every morning before breakfast
D). Measure the patients’ blood pressure every 4 hours
Weigh the patients every morning before breakfast
For standard precautions, which of the following is true?
1. "Hand Hygiene is the best way to prevent infection."
2. "Private rooms are necessary for your safety."
3. Respiratory hygiene and cough etiquette
4. PPE is acquired in a as needed basis
"Hand Hygiene is the best way to prevent infection."
Respiratory hygiene and cough etiquette
Wear PPE when your anticipated PT interaction is likely to involve contact with blood or body fluids.
Which protocol does not vary among institutions?
A. Acceptability of wearing artificial nails in patient care areas
B. Use of impervious transparent dressings to cover open lesions on nurse's hands during sterile procedures
C. Use of sterile gloves for sterile procedures
D. Sterile gloves are only available in "one size fits all"
Use of sterile gloves for sterile procedures
In which phase, do we measure if expected outcomes were met?
Evaluation
How is an Adult patient's ear positioned for ear medication?
pull pinna up and back (10 o’clock position) and apply pressure to tragus after
After administering a medication intravenously, the nurse assess that redness, tenderness and warmth is around the vein. What should the nurse do next?
STOP TRANSFUSION, Elevate & use warm compressions, and Inject into another extremities
For a C. diff patient, the nurse knows that gloves and gown are the appropriate PPE for Contact Precautions. Once leaving the room, the nurse removes the PPE, uses hand sanitizer and continues to the next patient. Is this appropriate?
No. Hands should always be cleaned with soap & water versus alcohol-based hand sanitizer. Clean & disinfect reusable equipment before use on another person.
The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first?
A. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%
B. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72
C. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84
D. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62
A. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%