Patient Assessment
Before administering IV antibiotics, what is the most important assessment?
History of allergies
A patient receiving IV fluids suddenly develops swelling, pain, and redness at the IV insertion site. What is the nurse’s priority action?
Discontinue the IV line immediately
A diabetic patient on insulin therapy suddenly becomes sweaty, shaky, and confused. What is the nurse’s initial action?
Check blood glucose level
FDAR stands for Focus, Data, Action, and this
Response
Before giving any medication, the nurse must check these identifiers to ensure the drug is given to the correct person
two patient identifiers (name and date of birth)
This scale is used to assess a patient’s level of consciousness.
Glasgow Coma Scale Glasgow Coma Scale
The nurse is inserting a nasogastric tube. Which action is most important to ensure correct placement?
X-Ray
A patient with congestive heart failure has a sudden weight gain of 2 kg in 24 hours. What does this most likely indicate?
Fluid retention
This form of communication ensures continuity of care among the health team.
nursing endorsement or handoff report
The “Five Rights” of medication administration include right patient, right drug, right dose, right time, and this final right.
right route
A patient with fluid overload may present with this finding on lower extremities.
pitting edema
This principle of body mechanics helps prevent back injury when lifting or turning patients.
bending at the knees and keeping a wide base of support
In patients with chronic kidney disease, this lab value is often elevated.
creatinine or BUN
When a nurse records “Patient ambulated 10 meters with minimal assistance,” this part of the nursing process is being documented.
implementation
When preparing medications, the nurse performs this safety check three times called the “Triple Check” or “Three Checks of Medication Administration” — when are these three checks performed
when taking the drug out, before preparing it, and before giving it.