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Nursing Process/Critical Thinking
Infection Control
Vital Signs
Safety
Activity/Mobility
100
The client states "My chest hurts and my left arm feels numb." The nurse interprets that this is what type of data?
What is SUBJECTIVE?
100
A client is lying in bed with 2 blankets. The nurse assesses the client's temperature, which is 100.4F. The client's skin is flushed. Blood cultures have been drawn and antibiotics started. This is your priority action:
What is remove blanket and offer hydration?
100
A client had oral surgery following a motor vehicle accident, and the nurse assessing the client finds the skin flushed, warm, and diaphoretic. This would be the best route to assess the client's body temperature:
What is tympanic or rectal?
100
Failure to properly identify patients can lead to injuries or death. Identify the number of patient identifiers and examples.
What is at least 2 (name, DOB, MRN)
100
These are 2 psychosocial effects of immobility.
What is hostility, fear and anxiety confusion sleep-wake cycle disturbances depression powerlessness
200
Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. This is part of which phase of the nursing process?
What is EVALUATION?
200
In the chain of infection, broken skin and invasive lines are considered _____________
What are portals of entry?
200
The CNA reports the following vital signs to you: BP 102/60, HR 70, R 24, T 99.4F and 96% SpO2. Which of these findings would be of greatest concern to the nurse?
What is Respirations?
200
Identify 3 of 6 components in the Morse Fall Scale.
What is History of fall Secondary diagnosis Ambulatory Aid IV/saline lock Gait/transferring status Mental status
200
What body systems can be affected by immobility?
What is ALL?
300
When deciding which patient to see, there are several frameworks that can be used. Name two.
What are MASLOW and ABCs?
300
Besides hand hygiene, these are two practices or interventions that promote medical asepsis.
What is change linens daily / clean equipment after use / do not place items on the floor (even soiled linen) / PPE / respiratory etiquette / lab specimens in biohazard bags / natural, short unpolished nails / remove jewelry / never shake linen / tie linen bag
300
Identify 2 common errors in blood pressure assessment.
What is Wrong cuff size Cuff wrapped too loosely Deflating too quick or too slow Arm too high or too low inflating too slowly repeating assessments too quickly
300
Name 4 interventions for patients at high risk for falls.
What is Identify risk safe room set up safety signage rounding Medications orient to environment bed low in locked position adequate lighting uncluttered bed alarms sitter nonslip footwear
300
Immobility can affect all body systems. Identify 2 possible respiratory findings in the immobile patient.
What is low O2 sat, crackles, wheezes, dyspnea
400
True or False. A nurse is demonstrating critical thinking when she explains the procedure for administering an enema step by step to a CNA.
What is FALSE?
400
Identify 4 principles of sterility.
What are 1) hands above waist 2) sterile supplies can only touch sterile 3) sterile field slightly above waist height 4) Only sterile objects on sterile field 5) keep dry 6) prevent prolonged exposure to air 7) Must stay within sight 8) 1 in border contaminated
400
In handoff report, the outgoing nurse indicates that a client's pulse volume is described as a 1. After receiving the report, the initial action of the nurse should be ______
What is to assess client immediately.
400
Restraints should only be used AFTER alternatives have failed. Identify 5 alternatives.
What is family bed alarms sitters distraction camouflage tubing/drains move near nurse's station answer call lights quickly identify pathophysiological reason for behavior if possible active listenign
400
Name two interventions that could be implemented for the immobile patient to prevent skin breakdown.
What is Manage moisture Optimize nutrition/hydration Minimize pressure
500
Eleven attitudes define the central features of a critical thinker and how this thinker approaches a problem. Identify 4 of these attitudes.
What are confidence, thinking independently, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility?
500
Your patient was admitted this morning with influenza. She also screened positive for MRSA in the nares. As the nurse, you will expect your patient to have these precautions. Additionally, you realize that this PPE will be required.
What is DROPLET and CONTACT? mask, gown and gloves
500
Your patient was admitted to the facility after falling at home several times. He states "When I get out of bed in the morning, I am just so dizzy". What is likely the problem? How do we "prove"?
What is orthostatic hypotension? Obtain BP and HR with patient in supine, sitting and standing positions (within 3 minutes of position change). While assessing, observe for symptoms of hypotension.
500
You enter the room and the curtains are on fire. What do you do first?
What is RACE Rescue patient
500
Name 4 important facts about performing ROM.
What are: Can be performed by RN, PT, or allied staff. Indicated for patients confined to bed for long periods May be performed passively or actively. Should be carried out smoothly and gently. Stop movement if patient complains of pain or there is resistance. Always support the joint distal to the one being exercised.