Infection
Control
Control
When should the nurse perform hand hygiene when providing routine patient care?
What is before and after every patient contact and after contact with potentially contaminated objects?
Name three basic interventions the nurse should use for a patient at risk for falling.
What is keep the bed low and locked, place the call light within reach, and provide nonskid footwear.
What is the expected resting respiratory rate for a healthy adult?
What is 12–20 breaths per minute?
What position should the nurse use when providing oral care to an unconscious patient?
What is side-lying, with suction equipment available.
What is the safest position for feeding a patient with dysphagia?
What is upright at approximately 90 degrees.
What must the nurse use before administering any medication?
What is at least two patient identifiers, such as the patient’s full name and date of birth.
Which common nursing procedure requires sterile technique?
What is insertion of an indwelling urinary catheter.
On which side should a patient with left-sided weakness hold a cane?
What is the right, or stronger, side.
The nurse notes that a patient’s radial pulse is irregular. What should the nurse do next?
What is count the apical pulse for one full minute.
What interventions help prevent pressure injuries in an immobile patient?
What is reposition the patient regularly, offload the heels, manage moisture, and inspect the skin routinely?
How should a patient obtain a clean-catch urine specimen?
What is cleanse the urinary opening, begin voiding, and collect the midstream urine without touching the inside of the container.
Can an enteric-coated tablet be crushed before administration?
No, crushing destroys the protective coating and changes where the medication is absorbed.
Which precautions are required for a patient with Clostridioides difficile iinfection?
What is contact precautions with a gown and gloves. Hands should be washed with soap and water.
When teaching a patient to use crutches on stairs, which leg moves first when going up?
What is the unaffected or stronger leg. “Up with the good, down with the bad.”
An automatic blood-pressure machine displays 78/42 mm Hg, but the patient is awake and denies symptoms. What should the nurse do first?
What is reassess the blood pressure manually using the correct cuff size and assess the patient.
How is a Stage 2 pressure injury described?
What is partial-thickness skin loss with exposed, moist, pink or red dermis; it may also appear as a serum-filled blister.
Where should the nurse obtain a urine specimen from a patient with an indwelling urinary catheter?
What is from the disinfected catheter sampling port—not from the drainage bag.
The nurse realizes that the wrong dose of medication was administered. What is the nurse’s first action?
What is assess the patient for adverse effects.
What personal protective equipment should the nurse wear when entering the room of a patient with active pulmonary tuberculosis?
What is a fit-tested N95 respirator.
Where should the nurse stand when assisting a patient who has right-sided weakness to walk?
What is sightly behind the patient on the right, or weaker, side while using a gait belt.
What blood-pressure change indicates orthostatic hypotension?
What is a decrease of at least 20 mm Hg systolic or 10 mm Hg diastolic within three minutes of standing.
A patient has right-sided weakness and is transferring from the bed to a chair. Where should the nurse place the chair?
What is on the patient’s left, or stronger, side.
What position should the nurse use when administering a cleansing enema to an adult?
What is left Sims’ position
Which task can the nurse delegate to unlicensed assistive personnel?
Obtaining routine vital signs for a stable patient.
What is the nurse’s first action after an accidental needlestick injury?
What is wash the area with soap and water, then immediately report the exposure according to facility policy.
A patient’s knees buckle while the nurse is assisting the patient to walk. What should the nurse do?
What is widen the stance, support the patient with the gait belt, bend the knees, and gently lower the patient to the floor while protecting the head.
A postoperative patient who received IV morphine is difficult to arouse and has a respiratory rate of 8 breaths per minute. Which medication should the nurse anticipate administering?
What is Naloxone?
While performing a sterile dressing change, the nurse’s sterile glove touches the bedrail. What should the nurse do?
What is consider the glove contaminated, remove it, perform hand hygiene as needed, and apply a new sterile glove.
A patient drinks 8 ounces of juice, consumes 6 ounces of soup, and receives 120 mL of ice chips. How much intake should the nurse document?
What is 480 mL?
Which patient should the nurse assess first?