Isolation
&
Sterility
&
Sterility
A patient is admitted with suspected influenza. Which transmission-based precaution should the nurse initiate?
What is droplet precautions, in addition to Standard Precautions.
A fire starts in a patient's room. According to RACE, what is the nurse's first action?
What is rescue anyone in immediate danger
How does using a blood-pressure cuff that is too small affect the reading?
What is it can produce a falsely high blood-pressure reading.
What is an early sign of hypoxia in many adult patients?
What is restlessness, anxiety, or a new change in mental status.
What must the nurse do before applying a new transdermal medication patch?
What is remove the old patch and assess the skin.
Which patient may an unlicensed assistive person safely feed?
What is a stable patient who has been assessed by the nurse and has no swallowing difficulty or aspiration precautions.
A patient with suspected measles arrives in the emergency department. What isolation is required?
What is airborne precautions in an airborne infection isolation room, with a fit-tested N95 or higher-level respirator for susceptible personnel.
What does PASS mean when using a fire extinguisher?
What is pull the pin, Aim at the base of the fire, Squeeze the handle, and Sweep from side to side.
How should the nurse determine an apical-radial pulse deficit?
What is two nurses count the apical and radial pulses simultaneously for one full minute and compare the rates.
Which nursing interventions help prevent postoperative atelectasis?
What is regular deep breathing and coughing, incentive spirometry, position changes, adequate pain control, and early ambulation.
Which technique is appropriate when administering subcutaneous heparin?
What is inject into an appropriate abdominal subcutaneous site and avoid aspirating or massaging afterward.
Which assignment is generally appropriate for an LPN/LVN?
What is administering scheduled medications and performing a routine dressing change for a stable patient, within state law and facility policy.
A patient has a draining wound infected with MRSA that cannot be fully contained by a dressing. Which precautions are indicated?
What is contact precautions with gown and gloves and dedicated or properly disinfected equipment.
A patient begins having a generalized tonic-clonic seizure while in bed. What actions should the nurse take?
What is protect the head, lower the bed, remove nearby hazards, turn the patient to the side when possible, time the seizure, and call for help.
A pulse oximeter reads 84%, but the patient is talking comfortably and has cold fingers. What should the nurse do first?
What is assess the patient and verify the reading by warming the hand, repositioning the probe, checking the signal, or using another site.
How can the nurse reduce hypoxemia during tracheal suctioning?
What is apply suction only while withdrawing, and keep each suction pass brief according to policy, generally no longer than 10 to 15 seconds.
An IV site is cool, pale, swollen, and painful, and the infusion has slowed. What complication is occurring, and what should the nurse do first?
What is the findings indicate infiltration; stop the infusion immediately.
An unlicensed assistive person reports that a previously oriented patient is suddenly confused. What should the registered nurse do?
What is assess the patient immediately.
During a sterile procedure, fluid soaks through the sterile drape from the surface underneath. Is the field still sterile?
What is no. The field is contaminated and must be replaced.
A patient develops chills, dyspnea, and back pain 10 minutes after a blood transfusion begins. What is the nurse's first action?
What is stop the transfusion immediately.
A postoperative patient's urine output has been 20 mL per hour for two consecutive hours. What should the nurse do first?
What is assess the patient and check the urinary system for a correctable cause, such as kinked tubing, dependent loops, obstruction, or bladder distention.
A patient suddenly becomes short of breath and has an oxygen saturation of 86%. What should the nurse do first?
What is stay with the patient, position upright, assess airway and breathing, and apply oxygen according to emergency protocol while calling for assistance.
How should the nurse administer several compatible medications through an enteral feeding tube?
What is give each medication separately and flush with water before, between, and after medications according to the patient's fluid plan and facility policy.
Which patient is most appropriate to assign to a newly licensed registered nurse?
What is a stable patient with predictable care needs, such as a postoperative day-two patient preparing for routine ambulation and discharge teaching.
The nurse prepares a sterile central-line dressing field, then turns away and leaves it unattended. What should the nurse do on returning?
What is a sterile field must remain continuously visible and under the nurse's control. Once it is left unattended or out of sight, contamination cannot be ruled out, and central-line care requires strict asepsis because microorganisms can enter the bloodstream.
A confused patient repeatedly pulls at an IV catheter. What should the nurse do before requesting a restraint?
What is assess and treat possible causes and try less restrictive alternatives.
A patient has a respiratory rate of 32, heart rate of 126, blood pressure of 86/48, cool skin, and new confusion. What is the priority response?
What is activate urgent or rapid-response assistance while supporting airway, breathing, and circulation.
The nurse observes continuous bubbling in the water-seal chamber of a chest-drainage system. What does this finding suggest?
What is an air leak in the system or from the patient.
A patient says, 'This pill does not look like the one I take at home.' What is the nurse's best response?
What is hold the medication and verify the order, medication record, and dispensed product before administering it.
Which patient should the nurse assess first: a patient waiting for discharge teaching; a patient requesting pain medication; a patient with a blood glucose of 68 mg/dL who is awake and drinking juice; or a postoperative patient who is newly restless with an oxygen saturation of 88%?
What is the postoperative patient who is newly restless with an oxygen saturation of 88%.