Safety and Infection Control
A patient is ordered to undergo a CT scan with contrast dye. The most important action for the nurse to take in regard to patient safety is to:
Check the patient’s allergy list.
Although encouraging fluids is important to flush out the dye, checking for linked dye allergies is more important for safety. The dye has iodine, which is linked to shellfish allergy.
A patient comes into the ER with COPD exacerbation and is having difficulty breathing. What action, if performed by the nurse, would be considered negligence?
The nurse places the patient on 4L of O2.
A patient with COPD should only receive low-flow oxygen- never more than 2L.
Excessive O2 removes a COPD patient's hypoxic respiratory drive causing hypoventilation with resultant hypercarbia, apnea, and ultimately respiratory failure
A new mother is admitted to the acute psychiatric unit with severe postpartum depression. She is tearful and states, “I don’t know why this happened to me! I was so excited for my baby to come, but now I don’t know!” Which of the following responses by the nurse is MOST therapeutic?
“Having a new baby is stressful, and the tiredness and different hormone levels don’t help. It happens to many new mothers and is very treatable.”
Postpartum depression is often hormonally-based and also has to do with support systems. Blaming the husband is not appropriate, nor is blaming the patient.
A graduate nurse prepares a patient to undergo a liver biopsy. The graduate nurse administers what pre-op medication?
Vitamin K
Vitamin K is administered before a liver biopsy to reduce the risk of bleeding. The liver is responsible for producing most of these coagulation factors. Some of these factors require vitamin K for synthesis.
Which questions would the nurse ask in identifying and planning culturally sensitive care for a newly admitted client?
1.What is your ethnicity or cultural background?
2.What are your pronouns?
3.What brought you in today?
4.What beliefs might impact your healthcare treatment?
5.What illnesses and hospitalizations have you previously had.
6.Who makes decisions in your family?
1,2, 4, 6
Rationale: 3 and 5 are not related to cultural sensitivity.
During report, the previous nurse emphasized that one of the newly admitted patients is on seizure precautions. The incoming nurse is correct when she performs which of the following actions to the client?
To protect a client with a known or suspected seizure disorder, the bed should be kept in the lowest position, decreasing the chance of injury from falling to the floor during seizure activity.
The charge nurse is supervising the nursing care administered on a busy medical/surgical unit. Which of the following situations, if noticed, would require immediate intervention?
The UAP should walk hand in hand with the patient with Meniere’s disease. The main characteristic of the disorder is attacks of dizziness that could cause a fall and injury. It is safest to ambulate with them.
The nurse cares for a ninety-two year-old patient whose wife recently passed away. Which of the following statements, if made by the patient to the nurse, requires further investigation?
“I gave away my favorite watch to my nephew the other day. I wanted him to have it, in case I’m not around for much longer.”
Giving away valuable possessions and making vague statements like “I may not be around” are signs of suicidal ideations. This comment needs to be further addressed.
A primipara is in the transition phase of labor on the maternity unit. On the fetal heart monitor, the nurse observes a contraction begin. Shortly after a delay, the fetal heart rate dips. It only recovers after the contraction has already ended for a period of 30 seconds. What action should the nurse prioritize?
Stop the Pitocin drip.
Reassure the mother.
Turn the mother on her left side.
Call the physician.
Stop the Pitocin drip.
Pitocin can cause the late decelerations that are described above. Reposition and give oxygen to the mom, then call the physician, and reassure the mother (psychosocial item is last).
A 5-month-old infant is brought to the clinic by his parents because he “cries too much” and “vomits a lot.” The infant’s birth weight was 6 lb, 10 oz (3,000 g), and his current weight is 7 lb, 4 oz (3,289 g), falling below the 5th percentile on a standard growth chart. Which data should the nurse identify as the priority:
1.frequency of regular checkups
2.feeding pattern
3.pattern of weight gain
4.family dynamics
Answer: feeding pattern
Rationale: Because the infant falls below the 5th percentile on a standard growth chart, the nurse should consider failure to thrive, a term applied to an infant who is not growing at an acceptable rate. Information about feeding patterns, including types and amounts of food, is needed to determine the cause of failure to thrive. If a child does not receive sufficient calories, growth slows.
Whether or not the infant has received regular checkups is important but not the priority because that information alone does not provide evidence or substantiation about the infant’s growth patterns.
The home health nurse visits the home of a client diagnosed with moderate-stage Alzheimer’s disease. The patient is pleasantly confused and lives with his son-in-law and daughter. Which of the following observations, if made by the nurse, is MOST concerning?
The door has a lock with a bolt.
Doors need to have locks in atypical locations (eg, tops of doors) to prevent the patient from nighttime confused wandering.
The nurse working on the diabetic specialty unit cares for four patients. A nursing assistant reports that each of the patients requires the nurse’s attention. Which of the following patients, if described as detailed below by the nursing assistant, should be seen FIRST?
The patient reporting hot, dry skin and fruity odor to breath shows signs of entering ketoacidosis and needs to be assessed immediately. The diabetes type one patient with low blood sugar (cool, clammy skin) is already eating a snack and should be seen second.
A 22-year-old patient and her husband come to the ER after a fall down the stairs. The patient has a black eye, avoids looking at the nurse, and gives yes/no answers to the nurse’s assessment questions. Which of the following actions should the nurse take NEXT?
The goal is to get the patient away from her potential abuser and ask her, face to face, “Are you being abused?” If so, you can offer help.
A client with myasthenia gravis is instructed to take anticholinesterase medications on time and to eat meals 45-60 minutes later. The client asks the nurse why the timing of the medication is so important. What is the nurse’s best response?
The nurse provides care for a client diagnosed with prerenal acute renal injury. Which action will the nurse perform first?
1. Assess history of prostate enlargement.
2. Insert an indwelling urinary catheter.
3.Monitor the client’s daily weights.
4.Assess the client’s blood pressure
Answer: 4. Assess the client’s blood pressure
Rationale: Decreased cardiac output and hypovolemia are causes of prerenal acute kidney injury (AKI). The nurse should ensure that the client's blood pressure is adequate to ensure kidney perfusion. Consider ABCs. Prioritize perfusion.
The medical/surgical nurse watches a student nurse prepare a sterile field. Which of the following actions, if performed by the student nurse, requires further instruction?
The student nurse cannot turn her back on the sterile field or it is no longer considered sterile.
The nurse answers the phone on a busy medical/surgical floor. A family member requests information on a patient by name. What response, if given by the nurse, is CORRECT?
“I cannot give you that information due to patient confidentiality.”
HIPPA means that you cannot give information out over the phone that even confirms a patient’s presence in the hospital. If the person is the POA (power of attorney), that is the only time you may give out information in person.
The nurse cares for a patient whose baby was born with unexpected spina bifida. Which of the following statements is MOST therapeutic to say to the parents?
Parents will be grieving the loss of the “perfect child” and need to hear what actions they can take so as not to feel helpless. The damage to the spinal cord done by spina bifida cannot be fixed.
A busy, harried-looking physician comes onto the floor and writes out four orders in less than one minute. He leaves, shoving over a stack of the nurse’s charting on the way out the door. Which of the following four orders should the nurse question?
The patient might have neuropathy and be unable to correctly sense the temperature of the heating pad, resulting in a burn.
A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6° F (38.1° C). Which outcome would be a priority for this client?
1.prevention of urinary tract complications
2.alleviation of nausea
3.alleviation of pain
4.maintenance of fluid and electrolyte balance
alleviation of pain
Rationale: The priority nursing goal for this client is to alleviate the pain, which can be excruciating. Prevention of urinary tract complications and alleviation of nausea are appropriate throughout the client’s hospitalization, but relief of the severe pain is a priority. The client is at little risk for fluid and electrolyte imbalance.
A nurse cares for a patient who has just returned from an endoscopy. The patient complains of a sore throat. The nurse knows that:
Sore throat is normal after an endoscopy.
The nurse in the outpatient care clinic cares for a client diagnosed with heart failure. Which of the following orders, if written by the physician, should the nurse question?
The rate listed is too high for a heart failure patient, who cannot handle so much fluid on their cardiac system.
The nurse observes that a preschooler who was admitted to the unit three days ago has enuresis. His mother is very upset and says, “But he hasn’t done that in years!” Which of the following responses, if made by the nurse to the mother, is MOST appropriate?
Children who have been admitted to the hospital may deal with this stress by regressing, or falling back on former behaviors. This is normal and temporary.
A patient with type I diabetes asks the nurse why he can’t take the new diabetic drug that he sees in the commercials. Which of the following is the best explanation for the nurse to give the patient?
“The cells that make insulin have been completely destroyed in your body, so drugs won’t work. You can only receive shots of insulin.”
Diabetes I means that the beta cells of the pancreas have been completely destroyed by the body. The patient will be unable to get any effect from the med because he doesn’t have the cells to use it!.
What therapeutic outcome does the nurse expect for a client who has received a premedication of glycopyrrolate?
1. increased heart rate
2. increased respiratory rate
3. decreased secretions
4. decreased amnesia
Answer: decreased secretions
Glycopyrrolate is an anticholinergic given for its ability to reduce oral and respiratory secretions before general anesthesia. Increased heart rate and respiratory rate would be adverse effects of the drug. Amnesia should not be an effect of the drug.
Keywork: premedication