Patient Safety
After the PCP makes rounds, the nurse notices that the physician wrote an order for a medication at triple the normal dose. What is the nurses next action?
A. Ask the nurse supervisor for advise
B. administer the medication as ordered
C. Contact the physician immediately
D. Call the pharmacy to see if the dosage is safe
C. Contact the physician immediately.
Giving the medication could cause harm, Rx is helpful but will not provide the answer.
When caring for a patient with viral hepatitis, the healthcare provider experiences a needlestick from a contaminated needle. Which of the following actions should the provider perform first?
A. Wash the area thoroughly with soap and water
B. Report to the emergency department
C. Make an appointment with the ID department
D. Put the needle in a biohazard bag for testing
A. Wash with soap and water.
after this the provider should follow facility protocol.
A second day post-op patient tells the day nurse "I was in agony last night, I couldn't sleep because of the pain!" which of the following is the nurses best response?
A. "Oh, I'm so sorry. You must be exhausted."
B. "Why didn't you just ask for pain medication?"
C. "Your pain doesn't seem to be well controlled."
D. "Did you tell the night nurse that you were in pain?"
C. Your pain doesn't seem well controlled
Shows listening to the patients concerns, restates the mesage
NCLEX- avoid "should" and "why"
Sorry- makes Patient a victim
A patient diagnosed with ulcerative colitis is admitted to the medical unit. When a nurse is assessing the patient, which of the following findings would be of the most concern?
A. Rebound tenderness
B. Borborygmi
C. Oral temperature of 99.0F
D. Blood diarrhea
A. Rebound tenderness
sign of peritonitis that could be a result of colon rupture (pain on removal of pressure).
Borborygmi is the sounds made by fluids and air moving in intestines.
A patient with the possible diagnosis of appendicitis. The nurse knows that a positive sign of appendicitis is:
A. Chadwick's
B. Homan's
C. Murphy's
D. Psoas
D. Psoas = inflammation of psoas muscle
Murphys: cholysistitis
Homans: DVT
Chadwicks normal in pregnancy
A nurse is caring for a patient with Meniere's Disease, which is the most appropriate safety consideration?
A. Maintain contact isolation measures
B. Raise side rails on the patients bed
C. Assist the patient to and from the bathroom
D. Restrict caffeine intake at breakfast
C. Assist to and from the bathroom
Meniere's is a disorder of the inner ear, causing vertigo, tinnitus, and progressive hearing loss. Due to unpredictable episodes of dizziness, the patient should be accompanied.
Side rails = restraint
A school nurse gives the teachers and staff an in-service on how tuberculosis is transmitted. Which of their statements indicates an understanding of the material being taught?
A. I can get TB is an infected person coughs near me
B. If i share food/drink with someone with TB, I can get it
C. If I come in contact with an infected persons blood I can get TB
D. I shouldn't have direct skin contact with anyone with TB
A. I can get TB is an infected person coughs near me
Airborne droplets,
A small plane carrying the football team from a local university crashes. Survivors are being transported to the hospital. Four team members died. Before the survivors reach the hospital, the nurse should anticipate being asked to do what?
A. Call the hospital's volunteer office
B. Call the nearest crisis response team
C. Alert the news station
D. Notify the university of the crash
B. Call the nearest crisis response team.
Increased need for support after a disaster requires crisis specialists
When assessing a patient with osteoarthritis, the nurse looks for which characteristic of this condition?
A. Bilateral joint swelling
B. Decreased grip strength
C. Waddling gait
D. Joint crepitus
D. Joint crepitus
grinding, grating, creaking or popping
RA: decreased grip and joint swelling
A nurse is caring for a patient with an implanted permanent pacemaker because of a complete heart block and severe bradycardia. Which of the following should the nurse assess to first determine pacemaker function.
A. Pacemaker insertion site
B. Blood pressure
C. Apical pulse
D. Electrocardiogram (EKG)
D. EKG
apical pulse will indicate that the pacemaker is functioning but will not indicate how often it is firing. EKG is the best way to determine actual pacing (pacer spikes).
An oncology nurse is with an adult client when a Code Pink is called overhead (infant abduction). What is the nurse's BEST action?
A. Remain with the patient, it's not a pediatric unit
B. Watch for someone with a large package
C. Check all empty rooms and closets
D. Evacuate all visitors to the hospital lobby
B. Watch for someone with a large package
Be alert to anyone that matches the description, is wearing bulky clothing or carrying a large package/bag.
Elevators may not work during a code pink- no evacuating.
Recently there has been an increase in clostridium difficile in an inpatient medical unit. What is the best method of preventing further spread among patients?
A. Clean rooms with bleach daily
B. Reinforce consistent hand hygiene
C. Assign patients to private rooms
D. Administer prophylactic antibiotics.
B. Reinforce consistent hand hygiene
most effective and preventing spread of nosocomial infections
Select all that apply: A patient is an orthodox Jew, Which foods are strictly forbidden in their diet?
A. Black coffee
B. Boiled shrimp
C. Turnip greens
D. Eggs and ham
E. Pork chops
F. Strawberries
B., D., E.
Kashrut is Jewish body of law dealing with food
Prohibited: pork, shellfish, scavenger fish, mammals that do not chew cud or have cloven hooves, food combos - mixing dairy with meat.
Select all that apply: Which are signs and symptoms consistent with the diagnosis of severe dehydration?
A. Bradycardia
B. Dizziness
C. Poor skin turgor
D. Dry oral mucosa
E. Decreased hematocrit
F. Tachycardia
G. Urine specific gravity of 1.008
B., C., D., F.
Increased Hgb/Hct, increased urine Sp.gr.
An unresponsive patient with diabetes is brought to the ER with slow, depp respirations. Additional findings include a blood glucose of 450, arterial pH of 7.2, urinalysis showing presence of ketones and glucose. Which of the following statements best describes the underlying cause of this patient's presentation?
A. hypoglycemia causes release of glucagon resulting in glycogenolysis and hyperglycemia
B. nocturnal elevation of growth hormones results in hyperglycemia in the morning
C. Lack of insulin causes increased counterregulatory hormones and ketone release
D. Hyperglycemia causes oxidative stress, renal dysfunction, and acidosis
C.
DKA is caused by insulin deficiency--> less glucose entering the cells, leading the body to break down fat and muscle for energy, resulting in ketogenesis and acidosis.
A patient with a Dx of schizophrenia is experiencing active hallucinations. Choose all the appropriate nursing actions.
A. distract the patient with a movie or game
B. Ask if any voices are telling him to hurt himself
C. Use therapeutic touch to reassure the patient
D. Agree with the patients impressions
E. Explain other are seeing the same things
F. Administer medications as ordered
B., F.
Safety is main concern. Don't touch or place in environment with increased stimuli.
A 69 year old female is admitted for a pneumonia caused by a gram-positive bacteria. Which of the following is a gram positive bacterium?
A. Pseudomonas aeruguinosa
B. Klebsiella Pneumoniae
C. Staphylococcus aureus
D. Escherichia coli
C. Staphylococcus aureus
Most common gram+
all others are gram-
A patient who has parkinsons disease states "I can't tie my shoe laces anymore." The provider recognizes that this patient problem is due to a deficiency in which neurotransmitter?
A. Serotonin
B. Glutamate
C. Dopamine
D. Norepinephrine
C. Dopamine
PD is progressive neurodegenerative disease that affects MOTOR system- dopamine helps the brain control movement and coordination.
PPD--> stop producing dopamine--> difficulty controlling muscles.
A. increased albumin levels
B. decreased creatinine clearance
C. Respiratory alkalosis
D. Iron-deficient anemia
E. metabolic acidosis
F. increased serum calcium
B., D., E.
Decreased creat clearance R/T decreased GFR
Serum creat/BUN increase
Metabolic acidosis- unable to excrete ammonia or reabsorb bicarb
No more erythropoietin from kidneys
Select all the apply: A patient with a T-4 spinal cord injury is at risk for autonomic dysreflexia. Which of the following are signs and symptoms of this clinical disorder?
A. Extreme hypertension
B. Diarrhea
C. Pale skin
D. Severe headache
E. Tachycardia
F. Blurred vision
A., D., F.
Emergent situation: sudden onset of extreme HTN, BRADYcardia, HA, blurred vision, FLUSHED skin, sweating above site of injury with goosebumps below injury. T6 and up
Common triggers: full bladder, restrictive clothing, fecal impaction
Select all that apply:
Which of the following are necessary for informed consent?
A. Risks as benefits
B. Length of procedure
C. Decision-making capacity
D. Reason for the procedure
E. Method of anesthesia
F. Alternative options
A., C., D,. F.
also risks of alternatives, Risk and benefit of not having procedure,
Select all that apply: During an outbreak of conjunctivitis (Pink eye), a school nurse sends a communication to parents about preventing further spread of the condition. Which recommendations are appropriate to include?
A. Avoid touching the face and eyes
B. Wear sunglasses when out
C. Stop using mascara for a week
D. Sanitize all flat surfaces
E. Wash hands often
E. Use a clean washcloth daily
A., E., F.
Sanitizer is Ok too, change pillowcases often, do not share personal items.
If infected, throw away all eye and face makeup, clean glasses and case, discard contact solution and replace lenses.
Select all that apply: A nurse id planning a presentation on PTSD at the Veterans Administration. Which are PTSD characteristics to include in the presentation?
A. Auditory hallucinations
B. Volatile emotions
C. Recurring nightmares
D. Difficulty concentrating
E. Easily startled
C., D., E., F
Some pts have visual hallucinations
Select all that apply. Which precipitating factors can trigger a sickle cell crisis?
A. Fever
B. hypoglycemia
C. overexertion
D. smoking
E. winter
F. dehydration
C., D., E., F.
Triggered by events that result in insufficient oxygen delivery to cells- overexertion, stress, dehydration, cold and smoking.
Select all that apply: A hospice nurse informs the family that their loved one will likely die within the next few days. Which are signs of the patients impending death?
A. gaunt and pale appearance
B. Scant, concentrated urine
C. decreased heart rate
D. Increased dysphagia
E. Refusal of protein supplements
F. increased disorientation and lethargy
A., B., D., F.
Death approaching can cause increased HR and RR with weaker cardiac contractions--> irregular and weak pulse. Less O2 in circulation pp> weakness, anorexia, decreased renal perfusion, and lack of O2 to brain--> confusion.