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Safety
Communication
Medications and Labs
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Quality
100
A confused older adult is in need of soft wrist restraints. Which of the following should the nurse include in the client's plan of care? a. Obtain a prn restraint order. b. Assess the placement of the wrist restraints, skin, and circulation every 2 hours or per policy and document. c. Place the client in a supine position after applying the restraints and secure the restraints to the side rails when in bed. d. Remove the restraints once every four hours to perform activities of daily living.
What is B. the standard of care for restraints is they can be applied only with a written order, which must be renewed every 24 hours. PRN is not acceptable. Restraints should be removed every two hours to perform activities of daily living. The condition of skin, circulation, and placement of restraints must be assessed every hour and documented.
100
If a nurse contacts the physician and the physician gives an inappropriate answer or gives no orders, the most appropriate way in which the nurse should document this is by: 1. Contacting the supervisor and completing an incident report. 2. Document the call in the chart, the information relayed, the fact that no orders were given, and an incident report was filed. 3. Completing a physician’s order and sending it to the nursing supervisor to obtain orders. 4. Documenting the call in the chart, the information relayed, and the fact that no orders were given.
What is Answer D If the physician gives an inappropriate answer or gives no orders, document the call, the information relayed and the fact that no orders were given
100
A nurse is preparing to administer digoxin (Lanoxin), clonidine (Catapres) and ditiazem (Cardizem). In promoting safety which intervention should the nurse complete first? a. Assess the client's vital signs. b. Instruct the client on the reasons for taking each med. c. Ensure the correct dose. d. Double ID the client.
What is a. If the client's vital signs are altered the nurse may not be able to administer these medications. After checking vital signs, ensure that the correct doses are available. Prepare to administer by double ID'ing the client, then tell the client about each dose as you give it.
100
The nurse is observing a student care for a client with a tracheostomy. The nurse should intervene if which of the following is observed? a. The student uses clean gloves to remove the tracheostomy dressing. b. The student cleans the inner cannula by soaking it in hydrogen peroxide per hospital policy. c. The student removed the soiled trach. ties and then replaces with a new trach. tie. d. The student replaces the dressing with a folded gauze 4x4.
What is C. to maintain safety apply new ties prior to removing old ties to prevent dislodgment of the trach.
100
The nurse is identifying strategies and techniques that can be used to investigate and evaluate errors that are occurring on her unit. The nurse decides that the most useful technique to use is which of the following? a. The rapid cycle test. b. A root-cause analysis. c. A failure mode and effects analysis. d. Define-measure-analyze-improve-control.
What is B When an error is analyzed, the primary causes need to be determined so that a workable and effective solution can be developed. A root cause analysis is such a process designed to investigate and categorize the root cause of the event. The Six Sigma DMAIC process (define, measure, analyze, improve, control) is used primarily for improving existing processes that do not meet institutional goals or national norms. Rapid cycle tests are components of continuous quality improvement. A failure mode and effects analysis (FMEA) is a procedure in product development and operations management for analysis of potential failure modes within a system for classification by the severity and likelihood of the failures.
200
A client has a sequential compression device that continues to alarm, stating high pressure. What is the nurse's priority action? a. Continue to use the device, checking it frequently. b. Ask another nurse to come in and trouble shoot the device. c. Replace the device and complete an incident report. d. Replace the device and complete a work order.
What is d. If there is any question regarding the functioning of a piece of equipment it should be removed and replaced with one that is functioning. A work order is placed for the malfunctioning equipment.
200
In using communication skills with clients, the nurse evaluates which response as being the most therapeutic? A) “Why don’t you stick to the special diet?” B) “I noticed that you didn’t eat lunch. Is something wrong?” C) “I think you need to find another physician that’s better than this one.” D) “We can’t continue talking about your financial problems right now. It’s time for your bath.”
What is B The nurse who is sharing an observation is using the most therapeutic response. Sharing observations often helps the client communicate without the need for extensive questioning, focusing, or clarification. A. This is an example of a nontherapeutic response. It is asking for an explanation. “Why” questions can cause resentment, insecurity, and mistrust. C. This is not a therapeutic response. It is giving a personal opinion. D. Changing the subject is not therapeutic.
200
A health-care provider (HCP) adds a second medication for blood pressure. Which combination of medications ordered should the nurse question? a. Metolazone (Zaroxolyn) and furosemide (Lasix). b. Iosartan (Cozaar) and bumetanide (Bumex). c. Captopril (Capoten) and hydralazine (Apresoline). d. Atenolol (Tenormin) and propranolol (Inderal).
What is d. When treating hypertension, each medication should be from different drug classes. Atenolol and propranolol are both beta blockers with the same mechanism of action.
200
A nurse notes that the client has an antibiotic ordered at 37.5 mLhr to be infused over 4 hours. When walking by the room the IV pump beeps, when she checks the pump she notes that the pump is set for 375 mL/hr and the bag is empty. What is the nurse's priority action? a. Document that it is complete early. b. Notify the client's nurse. c. Call pharmacy for advice. d. Notify the physician.
What is d. The first thing the nurse needs to do is assess the client. This is not an option in this question. Of the options listed her priority would be to notify the physician of the error and obtain further orders if need be.
200
An OR nurse is preparing for a client's procedure to begin. How should the nurse ensure that the correct procedure is being done on the correct client? a. Ask the client to state his or her name. b. Check the medical record for the correct client and date of birth. c. Apply the universal protocol and perform a "time out". d. Make sure the operative site is marked.
What is c. The joint commission's universal protocol for preventing wrong-person surgery and safe site protocol includes performing a time out to verify the correct procedure is being done on the correct client. The time out is a verbal confirmation of these measures by the surgical team.
300
A nurse is caring for a client who is to receive a unit of packed red blood cells (PRBCs). Which safety measure should the nurse implement when administering the blood transfusion? a. Monitor vital signs every 15 minutes during the transfusion to detect complications early. b. Administer the unit of PRBCs slowly over 5 hours to prevent a transfusion reaction. c. Stop the transfusion if a reaction occurs and administer 0.9% NaCl at the IV catheter hum to keep the IV patent. d. Deliver the PRBCs through an infusion pump with the standard tubing to ensure a consistent rate.
What is c If the client experiences symptoms of a transfusion reaction, the transfusion should be stopped immediately. The line should be kept open for emergency medications. Vital signs are assessed before the transfusion begins, 15 minutes after it started, and then hourly until the transfusion is completed and one hour after done. PRBCs should infuse in 4 hours or less to avid the risk of septicemia. Blood tubing is used.
300
A client with an IV line with a IVPB, oxygen per 2L/nc, and an as needed nebulizer treatment and a chest tube connected to a draining system. Several family members are present, wanting to be helpful and have been placing the oxygen back on when it slips, turning the IV pump off when it alarms, and placing the nebulizer tubing in the mouthpiece of the nebulizer. Which communication to the family is required for safe care of the client? a. Inform the family that they are not allowed to touch any of the medical equipment. b. Inform the family that they must get help from clinical staff when there is a need to connect tubing or devices. c. Thank the family for noticing when tubing is disconnected and getting the client the treatment required. d. Inform the family that they are only allowed to turn off the IV pump alarm.
What is b The nurse should inform nonclinical staff, clients, and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions. The family may touch the equipment; however, they should not operate any client care equipment including answering alarms and reconnecting tubing. the potential for incorrect reconnection exists. Tubing misconnections have resulted in death.
300
A client admitted with a MI has new orders: Aspirin 75 mg po daily, lisinopril 10 mg po daily, furosemide (Lasix) 10 mg po daily and potassium chloride (Kdur) 20 mEq po bid. The nurse reviews the following labs: K 4.2 mEq/L, creatinine 2.3 mg/dL, platelets 259 K/ml. Based on the results of the lab values, the nurse should plan to consult the physician before administering which medication? a. Aspirin. b. lisinopril (Zestril) c. Furosemide (Lasix) d. potassium chloride (Kdur)
What is b Aced inhibitors should be used cautiously in a client with renal impairment. Creatinine level of 2.3 is elevated and indicates renal impairment.
300
A nurse is assisting a physician during the placement of a central venous catheter, observes the tip of the catheter touching the hair that has fallen into the sterile field. Which is the most appropriate action by the nurse? a. Continue the procedure as you are not really sure it touched the hair. b. Immediately inform the physician of the break in sterile technique and obtain replacement supplies. c. Inform the physician that the tip touched the hair and let the physician decide what action should be taken. d. Obtain an antiseptic solution to cleanse the catheter tip so that it is free of micro-organisms.
What is b Contaminated supplies should never be used for a sterile procedure. A person who sees a sterile object become contaminated must correct or report the situation. The hair in the field contaminates the sterile field. The hair is not sterile. The nurse has a n ethical and legal responsibility to protect the client from injury. An antiseptic agent is one that inhibits the growth of some organisms but does not render an object sterile.
300
A nurse assists a client in placing a central venous catheter. The physician is offered a mask and gown but refuses to wear them. During the insertion, the nurse notices that the catheter touches the physician's shirt. The nurse speaks up and tells the physician that the catheter is contaminated. The physician disagrees and places the catheter. This is the second time the nurse has had an experience of unsterile technique with this physician. What is the best action to be taken by the nurse? a. Inform the client that the procedure was unsterile. b. Ask another nurse to go tell the nursing supervisor while discussing it with the physician. c. Review the institutional policy on reporting physician behaviors. d. Review the standards of care for central line placement with the physician.
What is c Nurse's have the responsibility to support standard of practice. When standards are not met, they must be reported to the appropriate person or agency. Most institutions have policies for unsafe practices, including those of physicians. The nurse does not have a duty to tell the client of the unsterile technique; however the nurse should monitor for signs of infection. The nurse should be accountable and take responsibility for reporting unacceptable practice and not ask another to report the event.
400
A nurse is caring for a client who has a white blood cell count of 2.8 K/mL. Which action is most important for the nurse to plan prior to initiating an IV? a. Requesting an order for prophylactic antibiotics. b. Placing a mask on the nurse and the client. c. Using antibacterial soap to cleanse the client's arm. d. Performing hand hygiene with alcohol-based rub.
What is d Since the WBC count is low, the client is at risk for infection. Alcohol-based hand rubs may offer better protections if hands are not visibly soiled. The first line of defense should be preventing the introduction of microorganisms.
400
The client in the critical care unit tells the day shift nurse that the night nurse did not answer the call light for almost 1 hour. Which statement would be most appropriate by the day shift nurse? a. "The night sift often has trouble answering the lights promptly." b. "I am sorry that happened and I will answer your lights promptly today." c. "I will notify my charge nurse to come and talk to you about the situation." d. "There might have been an emergency situation so your light was not answered."
What is c The nurse should have someone come talk to the client who is in a position to then investigate what happened on the night shift and determine why his happened. The day nurse does not have this authority. a makes the night shift look bad. b: the nurse has no idea what happened that to cause the delay, she also cannot assure that she or he will not be busy and not able to answer the light either this gives false reassurance.
400
The client with hypothyroidism and a diagnosis of myxedema coma is admitted to the critical care unit. Which assessment data would warrant immediate intervention by the nurse? a The client's blood glucose level is 74 mg/dL. b. The clients vital signs are T: 96.2 F; Pulse 54; Respirations 12, blood pressure 90/58. c. The client's ABG's are pH,-7.33; PaO2 78; PaCO2 48; HCO3 25. d. The client is lethargic and sleeps all the time.
What is c These ABGs indicate respiratory acidosis with ph< 7.35 and PaCO2 >45 and hypoxemia PaO2 <80. therefore this client would warrant immediate intervention.
400
A nurse is totaling the 8-hour I and O for a client with an IV infusing at 125 mL/hr. The total IV intake is 900 mL. Based on this information, which action should the nurse take? a. The IV pump is not functioning correctly and should be sequestered for inspection and replaced. b. The IV infusion stopped for two hours during a procedure and the intake is correct. c. Someone must have cleared the pump and forgot to document it. d. The IV pump has malfunctioned. The IV should be run off the pump at 125 mL/hr.
What is a The pump should have infused 1000 mL in 8 ours. The pump is not functioning and should be replaced with a functioning IV pump. If the pump had been turned off for two hours the intake would have been 850 mL. IV fluids should not be run off the pump.
400
A postoperative client is pulling at IV lines and a drainage tube. The client is disoriented to time, place, and person. A decision is made to place wrist restraints on the client to prevent tube removal. Which statement is true regarding the regulatory guidelines of restraint application and monitoring? a. A RN being an independent licensed practitioner can decide to apply restraints. b. An order to apply a restraint may come from the physicians standing order. c. Restraint application may be trialed for up to 2 hours before a physician order is required. d. Ongoing assessment and monitoring of the client's condition are crucial for prevention of injury or death.
What is d the improper use of restraints may result in injury or death. Ongoing assessment and monitoring of the client with reduce this risk. A RN cannot make the decision to apply restraints without consulting a physician. Standing orders may not be used to apply restraints. A physician order is required within 24 hours of application I the hospital setting. Restraint trials violate client rights.
500
A client with Parkinson's disease is noted to be at risk for falls. Which intervention by the nurse would be most effective in fall prevention? a. Assess the client on an hourly basis. b. Apply restraints to keep the client in bed. c. Make sure all furniture is out of his way. d. Instruct the nursing assistant to check the client more often.
What is a Assessing the client more frequently is the most effective intervention of the options provided. Restraints should only be applied if the client demonstrates noncompliance and a physician order is obtained for the restraints. Instructing the nursing assistant to check the client more frequently may be helpful; however the delegation lacks specific time frequency.
500
Nurse A is documenting administration of morphine in the EMR. Nurse A is called away to talk with the MD leaving the computer unattended. Seeing a free computer, Nurse B selects a different client for documentation. Nurse B is called away. Nurse A returns to the computer and completes documentation on Nurse B's client's record. Which nursing actions should have prevented this incorrect medical entry? (select all that apply) a. Log out of the system before leaving the computer. b. Check that the correct client is selected before documenting. c. Tell Nurse B to make sure to select the right client before documenting. d. Ask another nurse to complete the documentation. e. Always log in when accessing a record. f. Always use the assigned user ID and creased password when documenting in an EMR.
What is a, b, e, f. nurses should always log in with their personal user ID and password before documenting on a medical record and always log out before leaving the computer. never use another person's computer access. Always make sure the correct client is selected.
500
A nurse is hanging an IV solution ordered as D5NS with 20 mEq KCL. The nurse notices the label from pharmacy is correct as indicate; however, the solution in the bag is D5W. Which actions should be taken by the nurse to safely administer the IV infusion? a. Check for two client identifiers before administration. b. Consult the compatibility chart. c. Administer the IV solution. d. Call the pharmacist. e. First, initiate new stat orders for another client. f. Hold the medication until clarified.
What is d, f Even if the two identifiers are correct the nurse cannot administer this medication until clarified. Consulting the compatibility chart is ok, however it still doesn't effect that fact that the wrong solution is in the bag. The nurse should not administer the drug. Stopping to initiate another stat orders has nothing to do with safe administration of this med, and may distract the nurse resulting in forgetting to clarify or delaying clarification of the med. Holding the med is appropriate until clarified.
500
A nurse observes the following situations. Which situations would require the nurse to complete a variance (incident) report? select all that apply a. A daily medication given 2 hours later than scheduled. b. A physician who is angry with a delayed lab report. c. An incorrect narcotic count at the end of the shift. d. An incomplete lab draw ordered for the morning. e. A client falling out of bed and suffering an ankle fracture. f. A new nurse arriving late to work for the third time.
What is a, c, d, e An incident report is completed when a standard of care is breached or an unusual incident occurs. it is used for quality improvement in the agency and not used to discipline staff members.
500
A hospital recently formed a rapid-response team with the goal of reducing unexpected cardiopulmonary arrests. Which measures should be used to evaluate the performance of the RRT? Select all that apply a. The number of cardiopulmonary arrests. b. The types of supplies used during the RRT call. c. Evaluation of the team's actions. d. The outcomes of the clients following the RRT call e. The types of medications given during the RRT call
What is a, c, d Performance improvement requires that the process used to deliver services receives close and constant scrutiny. Monitoring outcomes including the number of cardiopulmonary arrests, evaluation of the team's actions, and outcome of the client will all serve to improve the RRT process.