Nurses agree to be advocates for their

patients. Practice of advocacy calls for

the nurse to
Seek out the nursing supervisor to resolve conflicts

Assess the patient's perspective and explain it when

necessary

Apply the law to the patient's clinical condition

Document all clinical changes in the medical record

every two hours

Nurses always strive to assess and understand their

patients. When they are able to identify a patient's personal
values and then accurately describe these values of the
client and defend the patient’s point of view, they can be a
successful advocate.
A nurse in the Neonatal ICU administers
adult-strength digitalis (Digoxin,
Lanoxin) to a 3-pound infant. As a
result, the neonate experiences
permanent heart and brain damage. The
nurse can be charged with
Negligence
Assault

Malpractice

Tort

The nurse could be charged with malpractice, which is

failing to perform, or performing an act that causes harm to
the client. Giving the infant an overdose, even if accidental,
is malpractice. Negligence is failing to perform the proper
standard of care for a patient; a tort is a wrongful act
committed on the patient or the patient's belongings; and
assault is a violent physical or verbal attack.
A client reports for same-day surgery
wearing expensive jewelry. What should
the nurse tell the client?
"We'll ask the supervisor to hold your jewelry until
you are in the recovery room."

"We keep all expensive items in the narcotic box, so

no one will take them."

"We'll put the jewelry in an envelope. We will both

sign it, and put it in our safe."

"We will tape the jewelry to you so it will remain

secure during surgery."

To ensure safety of valuables while a client is having a

procedure, the nurse should list the items on an envelope
before sealing it. Then the client and the nurse both sign
before placing the envelope in the safe.
An hour after a surgical procedure, a
male client who received a epidural
anesthesia requests to get up to go to the
bathroom. He still has an IV infusing
and is being assessed every 15 minutes.
What is the nurse's best response to
maintain client safety?
"Can you sit at the edge of the bed for a few minutes,
to see how you feel?"

"Let me get the nursing aide to help you, since it's

your first time getting up."

"Okay, first let's see how well you can stand and
bear weight. Then we'll decide."

"It would be better if you waited until the 15 minute

assessments are complete."

Before allowing the client to get up, the nurse needs to

know if he can bear weight and keep his balance. Unless he
is unstable, asking him to wait is not appropriate. Sitting at
the edge of the bed can avoid orthostatic hypotension, but
the nurse can't determine if the client can ambulate. Once
the client demonstrates that he can bear weight, assisting
him to the bathroom for the first time is a good safety
measure.
When caring for a patient with
Meniere's disease, which is the most
appropriate safety consideration?
Restrict caffeine intake after breakfast.

Assist the patient to and from the bathroom.

Raise the side rails on the patient's bed.

Maintain contact isolation measures.

Meniere's disease is a disorder of the inner ear. It causes

sudden vertigo, tinnitus, and progressive loss of hearing.
Due to unpredictable episodes of dizziness, the patient
should be accompanied when ambulating. Raising siderails
is considered a form of restraint and requires a doctor's
order.
The legal document that lists the
medical procedures and treatments a
person will refuse if unable to make
decisions is the
Patient Bill of Rights

Informed Consent

Advance Directive

Power of Attorney
An advance directive is a legal document that makes
provision for future health care decisions if the person is
unable to do so. It can include a Living Will and durable
Power of Attorney for Health Care.
Before touching a client who is crying, to
offer comfort, the nurse should consider
______.
the client’s recent vital signs

whether the client's family should be notified

the client’s cultural background

whether the client has been sad recently

While Western culture uses therapeutic touch as a way to

offer support or comfort, other religions or cultures see it as
a violation of privacy. For example, Asians or Muslims do not
welcome touch by strangers or by the opposite gender.
When in doubt, ask for permission or be conservative in your
approach.
After a patient's primary care physician
makes rounds, the nurse notices that the
physician wrote an order for a
medication that is triple the normal
dose. What should the nurse do?
Call the pharmacy to see if the dosage is safe
Administer the medication as ordered

Ask the nurse supervisor for advice

Contact the physician immediately

The nurse should call the physician who wrote the order as
soon as possible to clarify the order. Administering the
medication is incorrect because the nurse should know the
dose is outside the normal range. A pharmacist may be
helpful, but cannot change the order. Giving the medication
could cause harm to the patient, and the nurse could be
liable.
A nurse notices a discrepancy in the
medication records for a patient who has
orders for large doses of narcotics for
pain relief. What should the nurse do
first?
Notify the local police and narcotic division

Notify the pharmacy technician

Notify the unit's nursing supervisor

Notify the hospital's legal department

Every health care facility that stores and administers

controlled substances must have strict procedures for how
to control inventory. Discrepancies must be accounted for in
a timely manner. Documentation for loss/breakage/change in
orders is essential. If the narcotic count is not accurate, the
nurse should contact the nursing supervisor, who has
oversight of the unit.
A small plane carrying the football team
from the local university crashes and
survivors are being transported to the
hospital. Four team members died in the
crash. Before the survivors reach the
hospital, what should the nurse
anticipate being asked to do?
Call the hospital's volunteer office

Call the nearest crisis response team

Notify the university of the crash

Alert the local news station

After a traumatic event, there will be a great need for

support from disaster and crisis specialists. The survivors,
families of the deceased team members, fellow students,
and the community will need empathy and counseling. News
media usually monitor emergency radio, so they will already
be aware. Volunteers may be helpful, but are not experts in
assisting with disasters. The university will receive
information from other sources.
Which patient has the highest risk of
falling?
A 36-year old female with a fractured tibia.

A 63-year old male with angina pectoris.

A 75-year old female with episodes of syncope.

A 22-year old male with 3 fractured ribs and right

arm in a cast.

Because of age and unexpected syncope, the 75-year old

female is at the greatest risk of falling. The nurse should
observe the patient's balance and gait; the patient may
require assistance when ambulating, even when going to the
bathroom.
At what age should blood test screening
for lead poisoning in a low-risk child
begin?
18 months

24 months

6 months

12 months

The screening schedule is based on CDC recommendations,

based on research showing that blood lead levels increase
most rapidly at 6-12 months and peak at 18-24 months.
Starting at 6 months, a questionnaire should be used at
routine check-ups to assess the risk of high-dose lead
exposure. If risk seems low, an initial blood lead screening
test can be done at 12 months. If the result is < 10 µg/dL, a
second test is recommended at 24 months. If the result is
higher, more frequent monitoring is indicated.
Which statement is true regarding
medical legality?
Student nurses cannot be sued for malpractice while
in a clinical class setting.

A nurses who becomes ill and leaves during a shift is

not abandoning patients if the supervisor is notified.

A second trimester abortion may be obtained without

state involvement.

Consent for medical treatment can be given by a

minor with a sexually transmitted disease (STD).

The HIPAA Privacy Rule allows for treatment of an STD

infection without parental consent. The client is “advised” to
contact sexual partners but is not “required” to give names.
After age 13, permission from parents is not needed, based
upon current privacy laws. A minor is considered "the
individual" who can consent for STD treatment. Each state
has regulations regarding the stage of pregnancy when a
woman can legally obtain an abortion. Student nurses can
be held liable for their actions. Leaving a patient without
care is a form of negligence.
After instructing a client on how to
provide a urine sample for a stat
urinalysis, the nurse returns two hour
later to find the specimen in the client's
bathroom. The nurse should
Initiate an incident report for the delay.

Refrigerate the sample before sending to the lab.

Discard the urine and obtain a fresh specimen.

Immediately send the sample to the laboratory.

A urine sample that has been at room temperature for more

than 1 hour is not acceptable. The urine will become
alkaline and bacteria can begin to grow, leading to
inaccurate results. If a sample cannot be immediately
delivered to the laboratory, it should be refrigerated.
The following clients arrive for their
appointments at the diabetic clinic. Who
should the nurse see first?
A type 1 diabetes client who feels weak but is eating
a simple-carb snack.

A type 1 diabetes client who needs a dressing

change for his foot ulcer.

A type 2 diabetes client who will receive education

about her diet.

A type 2 diabetes client who presents with a

headache and a fruity odor on his breath.

The client with a headache and fruity odor to breath shows

signs of entering diabetic ketoacidosis (DKA) and needs to
be assessed immediately. The type 1 client with possible
low blood sugar is already eating a snack and should be
seen second.
When caring for a patient diagnosed
with viral hepatitis, the healthcare
provider experiences a needlestick with
a contaminated needle. Which of the
following actions should the healthcare
provider do first?
Put the needle in a biohazard bag for testing.

Report to the emergency department.

Wash the area thoroughly with soap and water.

Make an appointment with the infection control

department.

The puncture site and skin should be washed thoroughly

with soap and water. Then the healthcare provider will
follow the next steps in the facility protocol. The healthcare
provider will follow the facility-specific protocol for when a
needlestick occurs. Typically, after reporting the incident to
your supervisor, you will be directed to seek immediate
treatment.
When preparing a chart before
transporting a patient to surgery, which
document is NOT necessary?
Lab test results

Operative consent

History & Physical

Anesthesiology record

The anesthesiologist's note and record is not available until

the surgery is complete. The other documents should
accompany the patient to surgery.
Which of the following drugs should not
be refrigerated?
Ampicillin Oral Suspension

Epoetin alfa IV (Epogen)

Nadolol (Corgard)

Opened (in-use) Humulin N injection

Nadolol (Corgard) is a beta-blocker used to treat

hypertension and chest pain. It is stored tightly closed at
room temperature between 59 to 86 ºF (15 and 30 ºC) away
from heat, moisture, and light. Humulin N is a form of insulin.
After being opened, it is stored in the refrigerator or at room
temperature below 86 ºF . Humulin N must be discarded 31
days after opening. Ampicillin is a penicillin antibiotic. The
liquid suspension form should be stored in the refrigerator
for up to 7 days. Epoetin alfa !V is used for patients
undergoing chemotherapy or with anemia from serious
chronic diseases. It is stored in the refrigerator and should
be protected from light.
If a patient cannot read or write, the
nurse can read the consent form in front
of two witnesses. What else should the
nurse do?
Ask the hospital lawyer to assist with the consent

Ask the patient to make an "X" as a signature

Allow the Risk Management Supervisor to sign the

consent

Allow a family member to sign the consent form

The nurse can read the consent form in front of two

witnesses, and the patient can sign in their presence. The
patient must sign for himself, unless the patient is a minor
or not of sound mind. The nurse should never sign a consent
form for a patient.
The nurse can safely assign which task
to an unlicensed assistive personnel
(UAP) for a patient who is stable after a
myocardial infarction?
Answer the family's questions about aftercare.

Teach the patient about a heart-healthy diet.

Report any unusual lung sounds.

Measure and record intake and output.

UAP responsibilities are restricted to performing basic

nursing tasks, such as measuring I&O, vital signs, and
weight. They provide direct patient care, including bathing ,
feeding, and toileting. The licensed nurse is responsible for
assessment and education.
A second year nursing student has just
suffered a needlestick while working
with a patient that is positive for AIDS.
Which of the following is the most
significant action that nursing student
should take?
See a social worker immediately

Seek counseling
Start prophylactic Pentamidine treatment

Start prophylactic AZT treatment

Azidothymidine (AZT) treatment is the most critical

intervention and should be started within 72 hours after
exposure. It is an antiretroviral medication used to prevent
and treat HIV/AIDS by reducing the replication of the virus.
After exposure, prophylactic treatment with 2 or 3
antiretroviral medications is continued for 4 weeks.
Pentamidine is an antimicrobial medication given to prevent
and treat pneumocystis pneumonia. Talking to a social
worker or getting counseling may be appropriate later.
When assigning tasks to unlicensed
assistive personnel (UAP), the nurse can
ask them to do all the following EXCEPT
Report signs of skin breakdown

Measure intake and output

Provide patient and family education

Assist a patient who is choking

Unlicensed assistive personnel are not able to give

instruction or education to patients or family members. They
are also not permitted to administer medications, do
invasive procedures, or patient assessments. They can only
report what they observe, without interpretation or
assessment of the situation. They are also certified to give
emergency assistance. Providing education involves
assessing understanding and adapting the information to
meet the needs of the patient and family.
The purpose of holding a sterile gauze
pad on the site of an IM injection while
removing the needle is to
Prevent pathogens from entering through the
puncture.

Decrease the discomfort of the needle pulling on the

skin.

Increase the absorption of the medication.

Seal off the track left by the needle.

Pressing the gauze pad against the skin while removing the
needle reduces discomfort of the pulling sensation. Once
medication is completely injected, remove the needle using
a smooth, steady motion. Remove the needle at the same
angle at which it was inserted.
A pediatric nurse has been assigned to
assist with a bone marrow biopsy for a
7-year old girl. Conscious sedation will
be used for the procedure. What is the
nurse's primary responsibility?
Communication with the child's parents.
Monitoring the child during the procedure.

Application of the topical anesthetic ointment.

Documentation of the entire process.

Every procedure requires that one team member be solely

responsible for monitoring the patient. The nurse will
monitor the child's vital signs, reflexes, and response to the
procedure. The nurse will not leave the patient to update
any family members.
Performing a non-emergency invasive
procedure on a client without obtaining
informed consent can be considered
Fraud

Battery

Malpractice

Harassment

In medicine, battery is the intentional denial of a patient’s

right to direct their own medical treatments. An informed
consent must be obtained before giving non-emergency
treatment. If medical treatment is performed without the
patient’s consent or against their will, the patient may have
a claim for medical battery, even if the doctor did not intend
to cause any harm.
When coming back from lunch, the
nurse notices a male patient walking
alone in the hall. The patient is wearing
non-grip socks and the colored
wristband that indicates a risk for
falling. What is the first thing the nurse
should do?
Sit the patient in a chair and find the nurse aide.

Instruct the patient to walk only in his room.

Walk with the client back to his room and assist him
to get in bed.

Tell the patient to keep walking to build strength

A patient who is at risk for falls should be assisted when

ambulating. The nurse should accompany him back to his
room and assist him to get back in bed. Asking the nurse
aide to walk with him is acceptable, but the nurse should
stay with the patient until the aide arrives. Walking only in
his room will not build the patient's strength and stamina.
Any activity that causes fatigue is not recommended.
Title VI of the Civil Rights Act of 1964
specifies the right to
Use a sliding scale payment plan for all health care

Receive free medical benefits as needed

Have equal access to health care regardless of race
or religion

Choose any physician and healthcare coverage

Title VI prohibits discrimination on the basis of race, color,

or national origin in any program or activity that receives
Federal funds or other Federal financial assistance. Any
program that receives Federal funds cannot discriminate,
either directly or indirectly, in the type, quantity, quality, or
timeliness of services provided.
If a nurse applies a restraint vest
without the patient's permission or a
physician's order, the nurse may be
charged with
Invasion of privacy

Assault

Battery

Neglect

Restraining a patient or resident without consent or a

doctor's order is battery. Assault is the threat of harm, and
battery is the actual action of harm. Mechanical restraints
may also never be applied for staff convenience. Battery is a
criminal offense.
The intentional attempt or threat to
touch a person's body without the
person's consent is
Slander

Battery

Defamation

Assault

Assault is an intentional attempt or threat to touch someone

without their consent. There does not need to be actual
touching. If the person feels afraid of being harmed, assault
can be charged, even if there was no possibility of being
touched. A simple assault is when no harm is done. It is a
misdemeanor. Aggravated assault happens when a child,
elderly person, patient, or someone in a protected class is
threatened. It is a serious felony charge.
A 10-month old baby with a fractured
right femur is admitted to the pediatric
unit. Which action should the nurse take
first?
Do a quick physical assessment.

Administer pain medication.

Ask the hospital social worker to come to the unit.

Ask the parents how the fracture occurred.

In case of injury, especially among babies and children, it is

very important that the nurse should first assess possible
abuse. Reported suspected abuse is the responsibility of all
healthcare professionals.
Which ethical principle is used when a
client asks about her prognosis?
Nonmaleficence

Beneficence

Veracity

Fidelity

Veracity is the ethical principle that means to tell the truth.

There can be no mistruth or deceit. Beneficence is the duty
to do good and promote kindness. Fidelity is being faithful
and keeping promises. Nonmaleficence is the duty not to
harm, as well as prevent harm.
Which of the following conditions does
NOT require airborne contact
precautions?
Tuberculosis

Clostrididum difficile

Rubeola
Varicella zoster

Airborne precautions are added for clients who have

illnesses that are transmitted by airborne droplet nuclei,
such as chickenpox (varicella zoster), measles (rubeola),
and tuberculosis. C. difficile requires contact enteric
precautions.
A 50-year-old blind and deaf patient has
been admitted to your floor. As the
charge nurse, your primary
responsibility for this patient is?
Provide a secure for environment for the patient

Continuously update the patient on the social

environment

Let others know about the patient's deficits

Communicate with your supervisor about your

patient safety concerns

The American Disabilities Act (ADA) prohibits discrimination

against anyone who has a disability. Hospitals and health
care facilities must provide access and accommodation so
that patients, visitors, and staff are not at increased risk for
injury.
All of the following are able to sign their
own consent for a surgical procedure
EXCEPT
A durable power of health care

A patient who is 21 years or older

An unemancipated minor

An appointed guardianship

A guardian who has been appointed by a court has full legal

rights to choose management of care. An unemancipated
minor is under the control and authority of parents who can
provide consent. A patient who is 21 years or older can
provide consent for themselves. If a patient is not able to
make a medical decision, the durable power of health care
designee can consent.
A staff nurse is walking to lunch in the
main corridor of the hospital when the
code for infant abduction is announced.
What should the staff nurse do?
Go directly to the obstetrics unit to offer assistance
as required.

Observe people in the area who are carrying

oversized coats or large bags.

Quickly move to the hospital entrance and check

each person who leaves.
Contact the charge nurse of the nursery to obtain
details.

When an infant abduction is announced, every hospital

employee is responsible for looking for anyone who could be
concealing a baby. Oversized coats and large bags should be
suspected and reported. Hospital security will move to exits
to inspect anyone who is leaving. The OB unit doors will be
locked. Calling the nursery is pointless.
A train derails near your hospital. Over
25 people are injured and being
transported to the emergency
department. Which patient should be
assessed first?
A 10-year old with a severe leg laceration.

A 78-year old who has a compound fracture of the

left arm.

A 36-year old with a sucking chest wound.

A 23-year old who is unresponsive and has a high

spinal cord injury.

During a disaster involving mass casualties, difficult

decisions around priority must be made. The patient with
the sucking chest would can recover if given immediate
attention. The patient with the compound fracture and the
patient with the laceration can be given temporary care,
then fully treated later. The patient with the spinal cord
injury will not likely survive and should not be among the
first to be treated.
A patient who confused is left
unattended, with the side rails down and
the bed in a high position. If the patient
falls and breaks a hip, what can the
nurse be charged with?
Assault

Malpractice

Battery

Negligence

Negligence is failure to take reasonable caution to prevent

injury or harm to a patient. Not following basic standards of
care can result in pain and suffering, which is considered
negligence. In this case, basic safety guidelines of raising
the side rails, lowering the bed, and observing the patient
have not been followed. The patient has been placed at
unreasonable risk of harm, and the nurse could be sued for
negligence.
A child is admitted to the pediatric unit
with a diagnosis of suspected
meningococcal meningitis. Which of the
following nursing measures should the
nurse do FIRST?
Assess neurologic status

Institute seizure precautions

Document vital signs

Initiate respiratory isolation

The initial therapeutic management of acute bacterial

meningitis includes standard and respiratory (droplet)
isolation precautions. Initiation of antimicrobial therapy
should be immediate. Nurses should take necessary
precautions to protect themselves and others from possible
infection. Airborne or droplet isolation measures include: 1.
Wear a mask when entering the patient's room. 2. A single
patient room is preferred. If not available, spatial
separations of more than 3 feet and drawing the curtain
between beds is especially important. 3. When the patient is
transferred or leaves the room, they should wear a mask if
tolerated and follow respiratory hygiene.
The nurse reviews a patient's recent
orders and see that informed consent
must be obtained before tomorrow's
surgery. The nurse was not present
when the doctor explained the
procedure to the patient. When the
nurse brings the form to the patient,
which statement is best?
"What were you told about your surgical procedure?"

"Your surgeon asked me to make sure that you sign

the consent form."

"Do you have any questions about your surgery

tomorrow?"

"You have the right to change your mind at any

time."

Since the nurse was not in the room when the patient's
doctor explained the procedure, the nurse should assess
how much the patient understands. After listening, the nurse
can answer further questions, provide patient education, or
contact the doctor to get more information. As the patient's
advocate, the nurse should make certain that the patient
understands the surgery and is comfortable with the
procedure before signing the consent form.
The Emergency Department notifies the
pediatric unit of an admission of a 10-
year old with bacterial meningitis. What
type of isolation should be
implemented?
Droplet precautions

Contact precautions
Airborne precautions

Standard precautions

Bacterial meningitis is caused by exposure to through

respiratory droplets. The droplets are heavy, and fall within
3 feet of the patient. Droplet precaution, in addition to
standard precaution, requires a mask when giving direct
care or coming into close vicinity of the patient. Standard
precautions are general precautions taken with all patients.
The proper way to dispose of a used
needle and syringe is to
Cut the needle at the hilt in a needle cutter before
disposing of it in the sharps disposal container in the
patent's room.

Separating the needle and syringe and placing both

in the sharps disposal container in the patient's
room.

Recapping the needle and placing the needle and

syringe in the sharps disposal container in the
patient's room.

Place uncapped, used needles and syringes

immediately in the sharps disposal container in the
patient's room.

Never recap a used syringe. Place the uncapped, used

needles and syringes immediately in the sharps container in
the patient's room.
When a patient refuses treatment, this is
an example of
Common law

Statutory law

Civil law

Medical law

Common law allows a mentally competent adult to refuse

medical treatment, even if it hastens death. Also called case
or precedent law, it's based on past cases of a similar type.
Individual cases contribute to the precedence for resolving a
legal conflict. The right to refuse treatment is based on U.S.
cases from 1891 and 1914. The judgment of the 1914 case
(Schloendorff v. Society of New York Hospital) states, "Every
human being of adult years and sound mind has a right to
determine what shall be done with his own body..."
A nurse watches a new nursing assistant
care for a post-stroke patient with left-
sided paralysis. Which action by the
nursing assistant requires the RN to
intervene?
The nursing assistant places the patient in supine
position with head turned to the side.

The nursing assistant applies a gait belt around the

patient's waist prior to ambulating.

The nursing assistant tries to move the patient up in

bed by placing a hand under the left axilla.

The nursing assistant praises the patient for

attempting to perform all ADLs with minimal help.

The nurse should intervene because using the armpits to

pull a patient up in bed is not appropriate. Attempting to pull
on a flaccid shoulder joint could cause shoulder dislocation.
Always use a lift sheet for both patient and staff safety. All
the other actions are appropriate.
During initial rounds on the shift, the
nurse finds that a patient's TPN solution
has been infusing at a slower rate than
ordered. It is now 2 hours behind. What
should the nurse do?
Notify the physician to receive new infusion orders.

Continue at the same rate, and adjust the next bottle

to infuse faster.

Increase the infusion rate to return to the correct

amount.
Double the infusion rate for 2 hours, then return to
the ordered rates.

When TPN infusion rate changes by 10% (either increase or

decrease) the patient's blood glucose level can be
drastically altered. Always notify the physician to receive a
new order to adjust the rate.
While transcribing a physician's orders,
the unit secretary asks the nurse to
decipher an illegible medication order.
What should the nurse do?
Check the admission record medication list.

Clarify the medication by calling the physician.

Duplicate the previous medication order.

Clarify the medication with the pharmacist.

It is always the responsibility of the nurse to accept, verify,

and administer orders. Massachusetts is a good example of
a state Nurse Practice Act statement on the topic: "In any
situation where an order is unclear, or a nurse questions the
appropriateness, accuracy, or completeness of an order, the
nurse may not implement the order until it is verified for
accuracy with a duly authorized prescriber."
As the nurse prepares to witness the
surgical consent for a patient
undergoing a craniotomy for
glioblastoma, the nurse assesses the
patient's understanding of the
procedure. Because the nurse is the
patient's advocate, which statement by
the patient will cause the nurse to
contact the surgeon before signing the
informed consent?
"My surgeon described how the craniotomy will be
done."

"We talked about how my diabetes will affect healing

from the surgery."

"I will die if the tumor is not removed from my brain."

"There seem to be no major risks from this surgery."

Obtaining an informed consent requires an explanation

about the risks of the procedure. Surgery always involves
both surgical and anesthesia risks. Other components of
informed consent include potential complications; expected
benefits; the surgeon's inability to predict the exact
outcome; and other treatment options. The other responses
to this question are appropriate and indicate understanding.
After a patient arrives in the pre-op area
before his surgical procedure, the nurse
asks if he has any allergies. He says,
"Everyone has asked me that already!
It's on my chart! Can't you read it for
yourself?" The nurse should respond
"We ask with each new phase of treatment, for
verification and to keep you safe."

"You can expect to hear it again and again as you go

through surgery."

"I'm sorry! I'm required to ask that question for my

pre-operative checklist."

"We want to give you every opportunity to recall if

there are any additions or corrections."

Patients should be educated about the need to ask some

questions multiple times. This question is asked for
verification and safety with each new phase of treatment.
By asking, mistakes can be avoided.
The nurse demonstrates knowledge of
transmission-based standards by doing
which of the following?
Maintaining an adequate supply of masks in the
patient's room.

Assigning a patient to a semi-private room.

Sealing lab specimens in a ziplock biohazard bag.

Wiping a thermometer with antiseptic after each use.

All laboratory samples must be properly prepared and

labeled before transport. Specimen containers should be
tightened and secure. Place in a ziplock biohazard back and
seal the bag. Further packaging may be required, depending
on the type of precautions and laboratory protocols.
Due to a staff shortage, a nurse with only
six months of experience is puled from
his surgical unit to a medical unit.
Which patient assignment is most
appropriate for him?
A 68-year old who has just returned from a
bronchoscopy and biopsy

A 58-year old on airborne precautions for active

tuberculosis (TB)

A 72 year-old who requires instruction on an

incentive spirometer

A 69-year old with COPD who is on a ventilator

When a nurse is pulled (or "floated" to a different unit,

patients should be assigned that are compatible with the
nurse's experience. The nurse should be assigned the
patient who needs instruction on using an incentive
spirometer. Many surgical patients are taught about
coughing, deep breathing, and use of incentive spirometry
preoperatively. To care for the patient with TB in isolation,
the nurse must be fitted for a high-efficiency particulate air
(HEPA) respirator mask. The bronchoscopy patient needs
specific post-procedure care, and the ventilator-dependent
patient requires a nurse who is familiar with ventilator care.
A patient hospitalized with MRSA
(methicillin-resistant staph aureus) is
placed on contact precautions. Which
statement is true?
MRSA requires frequent contact, so the door should
remain open

Transmission can be prevented by hand hygiene,

gloves, and a gown

Risk for transmission is high, so the patient should

wear a mask

The patient must be placed in a room with negative

pressure

The CDC recommends a private room for patients requiring

contact isolation. Gloves, a gown, and a mask should be
used when caring for the client. Proper hand washing before
and after patient care is essential. The door should remain
closed, but a negative-pressure room. MRSA is spread by
contact with blood or body fluid or by touching the patient's
skin. It can be cultured from the nasal passages, so instruct
the patient to cover his nose and mouth when he sneezes or
coughs. A mask for the patient is not necessary.
When assessing a patient in the post-
anesthesia care unit (PACU), the first
thing the nurse should check
is________.
Level of consciousness

Ability to move

Respiratory status

Level of pain

The nurse should always begin by assessing the post-

operative patient's respiratory status. Breathing problems
are the second most common problem in PACU (nausea and
vomiting are first) Immediate post-anesthesia complications
can include airway obstruction, pneumothorax,
hypoventilation, or a pulmonary embolism.
The doctor orders a 24-hour ambulatory
electrocardiography using a Holter
monitor to a client with frequent
fainting spells. To obtain the most
accurate record, the nurse should
instruct the client to avoid which of the
following EXCEPT?
Using a cellular telephone.

Standing close to a microwave.

Shaving with an electric razor.

Eating with metal utensils.

Using electrical devices, such as electric razors and

toothbrushes, may alter the data recorded with a Holter
monitor. Patients are also generally advised to magnets,
microwaves, electric blankets, cell phones, and MP3
players.
In the event of a fire in a client’s home,
your first action is to _______.
get the fire extinguisher.

move the client to a safe place.

report the fire to your agency.

turn on the fire alarm.

The nurse should be familiar with exits and location of fire

extinguishers. If a smoke or fire alarm sounds, your first
action is to keep the client safe. Remember "R.A.C.E." to
quickly act. R = Rescue/Remove the client. A = Alarm, if the
alarm is not connected to the fire department, call 911 to
report it. . C = Confine/Contain the fire or smoke by closing
doors to prevent or slow the spread. Smoke is especially
dangerous for everyone. E = Extinguish the fire if possible,
using a handheld fire extinguisher. Attempt to extinguish
only small fires, as long as you and the client can remain
safe, and have an escape route.
When a patient asks to see her chart,
what should the nurse do?
Answer any questions without giving the patient her
chart

Call the doctor to get an order for the patient to read

her chart

Tell the patient she can see the chart when her
physician is present

Give the patient the chart and answer her questions

The patient has a right to see her chart. As the patient's

advocate, the nurse should answer any questions and
encourage the patient to become part of her health team.
The Bill of Rights for Patients has been in place since the
1960s. Every patient should be aware of their rights.
After a conference with the family, a
patient's care provider writes a Do-Not-
Resuscitate (DNR) order. What does the
understand when planning care for the
patient?
The patient and family may no longer make medical
decisions

DNR orders from a previous hospitalization will be

valid and legal

Nursing care will continue with the treatment orders

in place

Death will take place within the next 72 hours, so

family should prepare

A DNR order only controls CPR and similar life-saving

treatments. All other care and treatment continue as
ordered. Competent patients can still decide about their own
care, including rescinding the DNR order. A new DNR order
is written with each hospitalization.
According to the CDC, when removing
personal protective equipment (PPE)
which item is removed first?
Gown

Mask

Gloves

Goggles
The Centers for Disease Control and Prevention
recommends removing PPE in an order that minimizes
contamination from pathogens. Since gloves are the
"dirtiest," they are removed first. To make it easy to
remember, remove the PPE in alphabetical order: gloves,
goggles, gown, masks.
A pediatric nurse gets a call from the
Emergency Department that 2-year-old
is being admitted with a diagnosis of
febrile seizures. In preparing for his
admission, which of the following is the
most important nursing action?
Place a urine collection bag and specimen cup at the
bedside

Pad the side rails of his bed

Order a STAT admission CBC

Place a cooling mattress on his bed

With a diagnosis of febrile seizures, precautions to prevent

injury and promote safety should take precedence. Padding
the side rails is appropriate. Laboratory tests and a cooling
blanket must be ordered by the physician, and both may
have been done in the ED.
A 22-year old with terminal brain cancer
tells you that she as an Advanced
Directive for her end-of-life care. You
know this can mean any of the following
EXCEPT
Her family can direct the staff to keep her alive.

Her Living Will can indicate her wishes.

She can choose to be a DNR patient.

She can designate who can make her medical

decisions.

Advanced directives describe the kind of medical treatment

you want for yourself if you are in serious health condition or
unable to speak for yourself. Anyone over age 18 can have
an Advanced directive. Once in place, it is a legal document
that cannot be revoked. A person can choose to have a
Living Will, which lists the person's wishes regarding end-of-
life care. The person can also designate someone who can
make medical decisions if the person is unable to; this is
called the Medical Power of Attorney. A person can also
indicate they wish to be a DNR, or Do Not Resuscitate,
patient if their heart stops beating or they stop breathing.
During a staff meeting, the supervisor
reports on a recent infection control
audit. Which finding indicates a need for
staff training?
A lab technician puts on a mask, gown, and gloves
before entering the room of a patient on strict
isolation

A certified nursing assistant does not wear gloves

when feeding an elderly patient

A patient with active tuberculosis wears a mask

when going to another department for testing

A nurse with open lesions on her hands puts on

gloves before giving direct patient care

There is no need to wear gloves when feeding a client.

However, universal (standard) precautions (treating all blood
and body fluids as if they are infectious) should be followed
in all situations. A client with active tuberculosis should be
on respiratory precautions, including wearing a mask
outside his private room. Staff members with exudative
lesions or weeping dermatitis should not give direct care or
handle patient-care equipment until the condition resolves,
even if wearing gloves. Strict isolation requires the use of
mask, gown, and gloves for anyone entering the room.
When assessing gross motor skills, for
which infant should the nurse request a
developmental referral?
A 4-month old who is unable to sit without support.

A 9-month old who is unable to stand while holding

on.
A 6-month old who does not creep.

A 2-month old who does not roll over.

Over 90% of infants who are 9-months old can stand if they
have something to hold onto. Rolling over should occur
between 4-6 months; sitting without support is expected at
6 months. Creeping is normal at about 9 months.
A staff nurse working on the
gynecological surgery unit assigns the
unlicensed assistive personnel (UAP) to
ambulate a new post-hysterectomy
patient. Two hours later, the nurse
checks on the patient and finds that the
patient has not seen the UAP. When the
nurse discovers the UAP talking on her
phone in the lunch room, what should
the nurse do?
Report the UAP to the nursing supervisor.

Begin an incident report.

Remind the UAP that phones may only be used

during breaks.

Reprimand the UAP for her neglect.

While a staff nurse can delegate assignments to team
members, the nurse is not able to discipline a subordinate.
The nurse should notify the superior or the nursing
supervisor to handle the situation.
Before sending a client for a CT with
contrast dye, what the nurse's most
important action?
Verify that the informed consent is complete.

Teach about the need for post-procedure hydration.

Place the side rails of the bed up before transport .

Check the client's health record for allergies.

Checking the health record and asking the client about

allergies is most important. Contrast dye contains iodine,
which is related to shellfish allergies.
A 16-year old male calls the clinic
because he's worried that he might have
gonorrhea. However, he doesn't want
his parents to know. What should the
nurse tell him?
"I'm sorry, but you are a minor. We will need a
parent's consent before we can do anything."

"We can test and treat you. All results will be kept
confidential."
"We can test and treat you, but your parents will see
it on your chart."

"We can test you without parental consent, but if

there are positive results, we must notify the health
department."

Although some states have a minimum age for seeking

treatment for sexually transmitted infections (12-14 years)
adolescents are able to be seen without parental
notification and consent. The HIPAA Privacy Rule protects
the information, as well as prohibiting sharing it without the
client's permission. However, law mandates that certain
infections, including gonorrhea, be reported to public health
departments.
Prior to transport to surgery, the
operating room calls the unit nurse to
administer the preoperative medication
as ordered. After giving the medication,
the unit nurse discovers that the surgical
consent has not been signed. What
should the nurse do first?
Ask the patient to sign the consent before transport.

Notify the surgeon.

Call the OR to cancel the procedure.

Notify the nursing supervisor.

When reporting an incident, begin with the next person in

the chain of command. Depending on the facility, there may
be the need to complete a report for the Quality
Improvement or Risk Management departments. The nursing
supervisor may assume responsibility for the process or ask
the nurse to notify the surgeon and OR.
What precautions are necessary when
caring for a patient with Hepatitis A?
Wearing a mask at all times

Placing the patient in a private room

Wearing gloves for direct care

Gowning before entering the room

Hepatitis A is transmitted by the fecal-oral route. Unlike

hepatitis B and C, it is self-limiting and does not cause
chronic liver disease. Contact precautions are
recommended for patients with hepatitis A. No private room
is necessary unless the patient is incontinent of stool.
The Code of Ethics for Nurses was
written and published by the
National Institutes of Health

National League for Nursing

American Nurses Association

American Medical Association

The ANA Code of Ethics describes the obligations and duties

of every nurse. It is the nursing profession's non-negotiable
ethical standard. The latest revision was done in 2015. The
American Nurses Association was founded in 1898. The
National League of Nursing was founded in 1893.
The Quality Improvement Team is
considering an initiative to prevent falls.
Which action will be most successful?
Using color-coded wristbands.

Placing all beds in the low position.

Frequent rounds of patient rooms.

Putting a "Fall Risk" sign on patient doors.

When staff makes rounds, they are able to notice current

risks and can intervene right away. Rounds also provide the
opportunity for teaching patients and families about fall
risks.
Before administering a dose of
furosemide (Lasix) to a 2-year old with a
congenital heart defect, the nurse should
confirm the child's identify by checking
the hospital ID band and
Asking the child to tell you his name.

Asking the parent the child's name.

Verifying the child's room number.

Verifying the identity with a second nurse.

Standards of safe medication administration require

obtaining two patient identifiers before proceeding. For a
child, a parent can give the child's name. Many young
children do not know their full name, or are accustomed to
being called by a nickname. Adults can be asked their name
of birth date. Room numbers are not a reliable means of
verifying identification.
A patient is admitted to the unit with an
order for seizure precautions. Which
action is most appropriate?
Serve the client's food in paper and plastic
containers.

Maintain the client's bed in the lowest position.

Move the client to a room closer to the nurses'

station.
Ensure that soft limb restraints are applied to upper
extremities.

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.
Nurse Practice Acts are an example of
Civil law

Statutory law

Criminal law

Common law

Statutory law comes from authoritative and legislative

sources. Nurse Practice Acts are statutory laws regulated
by each state in the U.S. The states establish licensing
agencies or boards that oversee nursing practice.
When using a fire extinguisher, the hose
is aimed at the
base of the flame.

middle of the flame.

top of the flame.

area around the flame.

The Occupational Safety and Health Administration (OSHA)
states that the fire extinguisher nozzle should be aimed at
the base of the fire. Remember to use the PASS technique:
Pull, Aim, Squeeze, Sweep. Your facility will provide training
on fire emergencies every year.
A new patient is unable to perform oral
hygiene. Which of the following
instructions should the nurse give to the
nurse aide?
"Use a soft toothbrush to brush the patient's teeth
after every meal."

"Check the entire mouth each time oral hygiene is

done and document your observations."

"Use a soft foam applicator to swab the tongue,

gums, and lips every 2 hours."

"Rinse the patient's mouth with mouthwash a few

times during your shift."

A soft toothbrush should be used after each meal.

Mechanical action is necessary to keep the entire mouth
clean, stimulate the gums, and remove plaque. Assessing
the oral cavity is the nurse's responsibility. A foam
applicator does not adequately clean the teeth. Mouthwash
can irritate the mouth.
The nurse enters a client's room and
finds the client lying on the floor. What
should the nurse do first?
Call for help to get the client back in bed.

Determine if the client is responsive.

Ask the client what happened.

Assist the client to return to bed.

Always assess a patient after a fall or other incident. An

unresponsive client may have a head injury from the fall or
be in cardiac arrest.
When a patient is admitted with acute
influenza, what type of isolation is
MOST appropriate?
Reverse isolation

Strict isolation

Respiratory isolation

Contact isolation

Respiratory isolation is used to prevent transmission of

organisms by means of droplets that are sneezed or
breathed into the environment. Examples of such diseases
are influenza and tuberculosis. The patient and nurse should
wear a surgical mask during care. Visitors should wear a
mask and stay at lease three feet away from the patient.
The nurse should also educate family and visitors about
hand washing and cough etiquette.
Following surgery, the patient is
returned to the unit and complaining of
pain on a level of 9 out of 10. The nurse
reviews the chart and finds the surgeon's
order for "10 mg MSO4" written post-
operatively. Before administering the
morphine, what should the nurse do
first?
Set up a piggyback infusion system.

Contact the surgeon before proceeding.

Prepare the medication for administration.

Call the pharmacy to send up the morphine.

The surgeon should be contacted, because there is no

indication of how the medication should be given.
Remember the rule to prevent medication errors: the right
patient, the right drug, the right dose, the right route, and
the right time. Also, "MSO4" can indicate magnesium sulfate
as well as morphine. This order needs to be clarified.
Which is the priority for a child who has
returned to the unit after surgery to
repair a cleft palate and lip?
Managing pain

Ambulating every hour

Interacting with others

Preventing infection

Following any surgery, the first priority is preventing

infection. Besides antibiotics ordered by the surgeon, there
may be a need for restraints to prevent the child from
touching the incision. Pain management is also important,
but not the first priority. Ambulation and social interaction
are not initial concerns for the nurse.
Your home health client has been
throwing up for several days. You now
find her lying in her bed. She is pale,
lethargic, and her eyes are dull. She is
also anxious. Which of the following is
most likely?
Hypovolemic shock

Fecal impaction

Multiple sclerosis
Congestive heart failure

Although hypovolemic shock usually occurs from traumatic

injury, dehydration from vomiting or diarrhea can be a risk
factor. Fluids are replaced intravenously. Older patients are
more severely affected; hypovolemic shock can lead to
heart failure or stroke. Hypovolemic shock causes a feeling
of anxiety due to a decrease in circulating oxygen.
What kind of private health information
is protected by the HIPAA privacy rule?
Verbal

Written

Electronic

All of the above

Protected Health Information (PHI) is any information in a

chart or medical record that could be used to identify an
individual. It's a combination of health information and
personally identifiable information (PII) in any medium:
written, electronic, or verbal. Anything that can connect a
patient with their medical information is covered by the
HIPAA Privacy Rule.
A patient is transferred to the post-
anesthesia care unit (PACU) after
surgery with epidural anesthesia. After
taking the patient's vital signs, what
should the nurse assess next?
Bladder distention

Postoperative pain

Spinal headache

Ability to move legs

The perineal area is the last to regain sensation after

epidural anesthesia. The patient may not be able to feel the
urge to void, or may not be able to void. Checking for a
distended bladder is important to avoid bladder spasms from
overextension. If the patient is unable to void, the nurse can
get an order to catherize the patient. The other actions can
take place after assessing the bladder.
When making shift assignments, which
patient is most appropriate for a nursing
assistant?
A post-op laparotomy patient who needs education.

A post-hysterectomy patient who needs to ambulate.

A newly admitted patient with a seizure disorder.

A dehydrated patient with an electrolyte imbalance.

The nursing assistant helps with ADLs and can assist the
hysterectomy patient with ambulating, bathing, and other
basic care. The RN will be responsible for the other patients
who will require assessment, teaching, and other
interventions ordered by physicians.
What is the FIRST priority in preventing
transmission of infections?
Wiping stethoscopes with alcohol

Wearing sterile non-latex gloves

Wearing gowns and goggles

Performing proper hand hygiene

Handwashing remains the single most important way to

avoid spreading and getting infections. However, too often
nurses do not practice good handwashing techniques and
do not teach patients and families how to perform proper
hand hygiene. Nurses need to wash their hands before and
after every patient encounter.
A 16-year old male is brought to the
Emergency Department after a skiing
accident and requires life-saving
surgery. The family has been notified,
but will not reach the hospital for two
hours. What is the best way to obtain
consent for treatment?
Send the patient to surgery without a consent
Ask the family to sign the consent form when they
arrive

Obtain phone consent with a second nurse as a

witness

No consent is necessary in the event of trauma

In a life-saving emergency, if the family can be notified,

consent on behalf of the surgeon must be obtained.
Telephone (verbal) consent, with a witness, can be obtained
from the legal next-of-kin. Documentation of the consent by
the nurse and witness is required.
The most common cause of accidents in
the home results from
Burns

Falls

Lacerations

Abrasions

According to the National Safety Council, falls are the

number one cause of home accidents. For age 65 and older,
falls are the first cause of injury-related deaths, including
broken hips. Many falls can be prevented with simple
measures, such as removing small rugs and clutter, and
wiping up spills.
As the nurse prepares to administer
ampicillin 500 mg PO to a post-op
patient, he checks the capsule in the
patient's medication box. The dosage of
the capsule is not labeled, but the nurse
is familiar with the color and shape. The
nurse should
Give the capsule to maintain the schedule and blood
level.

Contact the nursing supervisor to report the error.

Call the pharmacy to bring properly labeled

medication.

Ask a second nurse to verify the medication as

ampicillin.

The nurse should never administer a medication that is not

properly abled, even if the nurse (or another nurse)
recognizes it. Call the pharmacy to deliver a properly labeled
medication. The nurse is able to handle the situation without
contacting a supervisor.
When signing a document as a witness,
your signature indicates that the patient
was of legal age and the correct person to be signing
the form

signed the document without coercion or distress.

Is fully informed about the form, including all

consequences

was alert and not medicated with narcotics.

Your signature as a witness only states that you have

verified that the person signing the form was the person who
was listed in the document.
Many lawsuits involving a nursing
professional happen when the nurse
documents the physician's errors

watches a new employee to verify skills level

abandons patients when going to lunch

follows an order that is incomplete or incorrect

Nurses are responsible for implementing doctors' orders.

They are also responsible for questioning the doctor about
an order that seems incomplete or incorrect. If an
inaccurate order is followed and the patient suffers harm,
the nurse can be held liable if the doctor was not contacted.
Always document communication with physicians when
questioning an order. If unsure, ask a supervisor.
When the clinic nurse calls a client who
has missed two check-up appointments
for her baby, the mother states that she
has issues with transportation. The
nurse should refer the mother to
The client's primary care provider

The local volunteer agency

The clinic social worker

Her health insurance company

The clinic social worker knows community resources that

can assist the client. These may include a local volunteer
agency that provides transportation for medical
appointments.
The home health nurse does an
assessment of a client with mid-stage
Alzheimer's disease who lives with his
son and the son's family. Which of the
nurse's observations should be
addressed first?
Extension cords are placed behind furniture.

The front door has a lock with a bolt.

Stove burners are turned on remotely.

Area rugs are in place, but secured to the floor.

The family seems to have taken measures to keep the client

safe. However, doors need to have locks in atypical
locations, such as the top of the door, to prevent the client
from wandering when confused. Conventional locks can
easily be opened.
Which of the following tasks can be
assigned to an experienced certified
nursing assistant (CNA) who is helping
care for a patient on a ventilator?
Report when the endotracheal tube requires
suctioning.

Measure vital signs and pulse oximetry readings

every 4 hours.

Check ventilator settings with the respiratory

therapist.

Document lung sounds every 4 hours.

The certified nursing assistant’s educational preparation

includes measurement of vital signs how to check oxygen
saturation by pulse oximetry. Asking a CNA to do a task
beyond their education level is beyond their scope of
practice. Assessing and observing the patient, as well as
checking ventilator settings, and suctioning require the
additional education and skills of the RN.
After the hospital Quality Improvement
Team discovers a sudden increase in IV
site infiltrations on a surgical unit, they
implement a Plan-Do-Study-Act (PDSA)
initiative. Which step will come first?
Monitor which IV needle gauges are used.

Analyze the data.

Perform chart audits.

Implement a new IV insertion policy.

A quality improvement initiative begins with agreeing on

what aspect of a problem to study. Plan: In this case, the
team suspected that needle gauge was a factor. Do: A chart
audit is performed, then the data are analyzed, or studied.
The "Act" phase is the decision to implement a new policy.
During the completion of a routine pre-
operative checklist before transport to
surgery, the patient tells the nurse about
an allergy that is not on the health
record. What should the nurse do first?
Tape a note to the chart
Notify the OR charge nurse

Proceed to give the pre-operative medication

Contact the anesthesiologist

The anesthesiologist (and nurse anesthetist) must have all

knowledge about the patient's medical information, because
they monitor the patient's physical condition during surgery.
If any new information is available prior to transporting the
patient, a direct call to the anesthesiologist is required, to
ensure patient safety.
Which of the following is NOT
considered to be Private Health
Information (PHI)?
Pedometer log

Social Security number

Driver's license number

Email addresses

There are specific identifiers in medical records that can

potentially identify an individual or be traced back to
individual. This could result in revealing information about a
person's health care services, including diagnosis and
treatment. A pedometer log is not linked to health records,
so it's not considered to be PHI. Other examples of PHI
include any address information lower than state level;
dates; telephone and fax numbers; medical record numbers;
vehicle identification numbers and license plate numbers;
names of family members; and device serial numbers.
When the nurse realizes that a patient
has received the wrong medication, what
is the nurse's first action?
Assess the patient's condition

Report the error to the unit manager

Initiate an incident report

Notify the physician of the error

After recognizing that a patient has received the wrong

medication, the nurse should first assess the patient for any
complications or side effects. Reporting the error and
completing an incident report can come later, but the
patient's safety comes first.
What is the first step when planning
nursing care for a patient with a
different cultural background?
Encourage the family to provide care to maintain
customs and rituals.

Assess cultural variables that could impact the

patient's treatment plan.
Explain why the patient must follow hospital's
protocols.

Speak slowly and use a picture board to ensure that

the patient understands.

Without identification and assessment of the patient's

cultural needs, the nurse can understand how customs and
rituals might influence the diagnosis, treatment or health
care management.
On reporting to his Med-Surg unit, a
nurse is told that he has been pulled to
ICU. The nurse has never worked in ICU
and is hesitant to "float" for his shift.
What should he do?
Check with the hospital's attorney

Refuse to float in the ICU

Go to the ICU and perform safe tasks

Call the nursing supervisor

Being floated or pulled to another unit is acceptable and

legal. The new unit should provide orientation before being
assigned to stable patients that are similar to those
normally cared for, in order to provide safe care. Refusal to
float can result in termination.
A patient who is right-handed is groggy
and confused after surgery. The patient
continues to pull at the IV inserted into
his left arm. What is the least restrictive
restraint to maintain the IV site?
Bilateral soft wrist restraints.

Right arm tie restraint.

Safety mitts for both hands.

Safety mitt for the right hand.

A single safety mill permits arm movement while preventing

the patient's hand from grasping the IV tubing. The Joint
Commission Standard PC.03.05.01 states that restraints may
only be used "when less restrictive interventions are
ineffective" and that the restraints "are discontinued at the
earliest possible time."
A client comes to same-day surgery for a
minor procedure. Which of the following
is most important for verification of the
client's identity?
Driver's license

Admitting record
Identification bracelet

Addressograph labels

Placing the identification bracelet on the client is the most

important step. All healthcare staff will refer to the bracelet
throughout the entire procedure. Admitting record and
addressograph labels are necessary, as well. A driver's
license is not part of the identification process.
The nurse has been assigned four
patients . Which patient should the
nurse assess first?
A 16-year old scheduled for her first physical therapy
treatment.

A 34-year old with copious secretions from a new

tracheostomy.

A 52-year old diabetic who will be discharged to

home.

A 77-year old who needs a dressing change for a

pressure sore.

The patient with tracheostomy should be assessed first.

There is a risk of a compromised airway from the secretions.
Remember Airway, Breathing, and Circulation (ABC) is
always the priority.
Which is an appropriate for including in
a staff nurse's performance evaluation?
General praise for the nurse's abilities.

Input from other staff nurses.

Documentation of skills needing improvement.

List of strengths and weaknesses.

A performance review should provide a complete picture of

how a nurse is doing at a given point. This includes an
evaluation of the nurse's strengths, as well as opportunities
for further learning or improvement.
A 22-year old female with a history of
type 1 diabetes is brought to the
emergency department. Which
respiratory pattern indicates diabetic
ketoacidosis (DKA)?
Deep, rapid respiration rate with long exhales

Shallow respirations with irregular long expirations

Regular respiratory pattern, but frequent pauses

Short inspirations and expirations

Deep, rapid respirations with long expirations (Kussmaul's

respiration) indicate metabolic acidosis. As the body
attempts to get rid of carbon dioxide and acetone, breathing
increases in depth and rate. The breath has a "fruity" scent.
Other signs of DKA: excessive thirst, nausea, vomiting,
abdominal pain, weakness, and confusion. DKA can be life-
threatening and requires rapid treatment.