Infection
Prevention
Prevention
Glucose
Control
Control
Pressure
Injury
Injury
Suctioning
Safety &
Mobility
Mobility
200
After providing incontinent care, the nurse needs to access the same patient’s central-line tubing. This must occur before moving from the contaminated task to the clean task.
What are removing gloves, performing hand hygiene, and applying new gloves as indicated?
200
A finger-stick result is unexpectedly high immediately after the patient ate fruit with bare hands. This action helps determine whether glucose residue affected the result.
What is wash and thoroughly dry the patient’s hands and repeat the test with a new strip and puncture site?
200
A patient’s sacrum is intact but has localized redness that does not turn white when pressed.
What is a Stage 1 pressure injury?
200
This rigid suction device is used to remove thick secretions from a patient’s mouth and oropharynx.
What is a Yankauer suction tip?
200
After sitting on the side of the bed, a patient reports dizziness and begins leaning backward. This is the nurse’s priority action.
What is support the patient, return the patient to a safe sitting or lying position, and assess before attempting to stand?
400
A patient with uncontrolled wound drainage is placed on Contact Precautions. Name the PPE the nurse generally applies upon room entry.
What are a gown and gloves?
400
An alert patient receives 15 grams of rapid-acting carbohydrate for a glucose of 61 mg/dL. Fifteen minutes later, the glucose is 67 mg/dL. This is the next action.
What is repeat 15 grams of rapid-acting carbohydrate and recheck again in 15 minutes?
400
The nurse observes full-thickness skin loss with visible adipose tissue and granulation tissue. No muscle, tendon, or bone is exposed.
What is a Stage 3 pressure injury?
400
Gurgling respirations, visible secretions, an ineffective cough, and increased work of breathing indicate the need for this intervention.
What is oropharyngeal suctioning?
400
A patient has left-leg weakness and uses a cane. State which hand holds the cane and the correct walking sequence.
What is hold the cane in the right hand, advance the cane with the weak left leg, and then advance the stronger right leg?
600
Place these items in the correct order for donning: gloves, eye protection, gown, and mask or respirator.
What are gown, mask or respirator, eye protection, and gloves?
600
The nurse cleans a finger with alcohol and punctures it before the alcohol dries. This testing problem may result.
What is an inaccurate or diluted blood sample?
600
A patient’s heel has intact skin with a persistent dark red, maroon, or purple discoloration after prolonged pressure.
What is a deep-tissue pressure injury?
600
To reduce mucosal injury and hypoxemia, suction should be applied during this phase and limited to no longer than 15 seconds.
What is while withdrawing the suction device?
600
A patient with right-leg weakness uses a walker. State the correct sequence for ambulation.
What is advance the walker, move the weak right leg forward, and then move the stronger left leg?
800
While removing PPE, the nurse’s bare hand accidentally touches the contaminated front of the gown. This is the immediate response.
What is stop and perform hand hygiene immediately before continuing?
800
A patient is awake but cannot safely swallow and has a glucose of 49 mg/dL. Explain why orange juice is unsafe and identify the appropriate response.
What is aspiration risk; use the facility’s severe-hypoglycemia treatment protocol, such as IV dextrose or glucagon as ordered?
800
Slough and eschar completely cover a pressure injury, preventing the nurse from determining its true depth.
What is an unstageable pressure injury?
800
During suctioning, the patient’s heart rate suddenly decreases from 84 to 46 beats/min. This is the nurse’s priority action.
What is immediately stop suctioning, remove the device, oxygenate, and reassess the patient?
800
An unconscious patient cannot state a name or birth date. Explain how the nurse should verify identity before collecting a specimen.
What is compare at least two identifiers on the identification band with the order and medical record?
1000
DAILY DOUBLE
A nurse completes perineal care and, without changing gloves, begins changing the patient’s abdominal dressing. Identify two breaks in infection prevention.
What are failing to change gloves and failing to perform hand hygiene between a contaminated and clean procedure?
1000
After treatment, a patient’s glucose increases from 55 to 91 mg/dL, but the next meal will not arrive for two hours. This additional intervention may prevent recurrence.
What is provide a longer-acting carbohydrate with protein, according to the patient’s diet and protocol?
1000
A pressure injury caused by an oxygen tube is found inside the patient’s nostril. The nurse should document its location and cause but should not assign this.
What is a pressure-injury stage? Mucosal membrane pressure injuries cannot be staged.
1000
A stable patient requires routine Yankauer suctioning. This task may be delegated, but the RN retains responsibility for these two actions.
What are assessing and documenting the patient’s respiratory status?
1000
A confused patient cannot follow directions or bear weight during a transfer. This is safer than attempting a manual pivot transfer.
What is using the prescribed mechanical lift with appropriately trained staff?