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In the acute/critical care setting, patients who are critically ill or unconscious, may not be able to self-report, resulting in excess pain relating to ICU procedures, injuries, etc. According to the principles of justice, respect for human dignity, beneficence, and nonmaleficence, nurses have a duty that encompasses what?
A. Provide pain management and comfort to all patients. B. Continually provide opioid analgesics to the patient to avoid pain while they’re awake. C. Monitor only vital sign changes to assess for pain. D. Only provide pain relief when the patient is awake.
A. Provide pain management and comfort to all patients.
When a patient is in a critical care unit, nurses must always assess pain regardless of the patient’s condition, status, or ability to self-report. What must nurses remember when conducting an assessment with a patient who is unconscious or sedated?
A. The patient doesn’t understand how to self-report because they have been unconscious. B. Self-reporting isn’t the best option for patients in this setting C. That patient status and self-report can be altered due to delirium, cognitive, or communicative limitations. D. Nurses must control pain based on their own patient assessment.
C. That patient status and self-report can be altered due to delirium, cognitive, or communicative limitations.
Each unit sets recommendations to ensure nurses are providing the best quality care. Clinical practice guidelines are evidence-based practices that nurses must use to ensure optimal health. Which of the following is a Recommendation Based on Evidence that HCPs can use to ensure adequate pain management in critically ill/unconscious patients?
A. Observation of Patient Behavior B. Assessing/monitoring for potential pain causes C. Family reports based on their relationship with the patient and their knowledge of the patient’s behaviors D. All the above
D. All the above
What conditions would increase the risk for developing heart failure? A. Obesity and HTN B. Maintaining a healthy BMI C. BP of 120/70 D. Not smoking
A. Obesity and HTN
What suggestion would a nurse make to a patient to help lower their risk of heart failure? A. Eat a high fat and high sugar diet B. Avoid exercise C. Monitor blood glucose level D. Decreasing smoking is not necessary because it does not increase risk of heart failure
C. Monitor blood glucose level
What is an early detection technique for heart failure? A. Cardiac MRI B. Cardiac catheterization C. Assessing patients risk factors D. All of the above
D. All of the above
Although there are several locations to gain venous access, there is one that tends to have worse success. Which of the following locations should you avoid placing a peripheral venous catheter if possible? A. Hand B. Forearm C. Antecubital D. Wrist
C. Antecubital
Transparent dressings for intravenous catheters (IV) are changed frequently for various reasons, however there is a standard of care. How often should the transparent dressings for IVs be changed if they are not soiled? A. Every 2 days B. Every 4 days C. Every 5 days D. Every 7 days
D. Every 7 days
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client’s intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has occurred? A. Infection B. Phlebitis C. Infiltration D. Thrombosis
C. Infiltration
The nurse goes into the patient’s room to draw a blood culture. She beings by washing her hands, applying clean gloves. After finding an appropriate vein, the nurse cleans the site for 30 seconds with 70% isopropyl alcohol and allows the cleansing site to air dry before she uses a butterfly catheter to waste 1-2mL of blood and then obtains the culture specimen. Which of these steps did the nurse complete incorrectly, according the guideline’s best practice? A. Wasting 1-2mL of blood B. Cleansing the site for 30 seconds C. Wearing clean gloves D. Utilizing 70% isopropyl alcohol as the cleaning agent
C. Wearing clean gloves
What are potential consequences of false positives with contaminated blood cultures? Select all that apply
A. Longer hospital stays B. Unnecessary antibiotic use C. Fewer diagnostic tests D. Decreased cost of stay E. Inaccurate diagnoses
A. Longer hospital stays B. Unnecessary antibiotic use E. Inaccurate diagnoses
Which of the following does not match the inclusion or exclusion criteria for the clinical practice guideline literature search?
A. Studies published in English---- inclusion B. Studies from October 2012-June 2016---- inclusion C. Studies involving human subjects---- exclusion D. Studies not addressing the PICOT question---- exclusion
C. Studies involving human subjects---- exclusion
The nurse is planning to assess a patient with SCDs. Which assessment finding best indicates that the SCDs are accurately working?
A. Assess pedal pulses B. The patient is wearing them C. The medical prophylaxis devices are fitted properly and are always in use D. Skin is warm to the touch and normal color for ethnicity
C. The medical prophylaxis devices are fitted properly and are always in use
There is evidence that supports using mechanical prophylaxis measures to be successful. If added with anticoagulant therapies, what risk should we be concerned about?
A. PTT between 25 – 35 B. Bleeding risk C. Pedal pulses 2+ bilaterally D. Glasgow Coma Scale of 15 D. Glasgow Coma Scale of 15
B. Bleeding risk
As shown through evidence the use of SCDs and low molecular weight heparin (LMWH) decrease venous thromboembolisms. What medication can you give to the patient if LMWH and SCDs are contraindicated?
A. Acetaminophen (Tylenol) B. Enoxaparin (Lovenox) C. Aspirin D. Levetiracetam (Keppra)
C. Aspirin
The nurse is teaching the client how to care for her ostomy. The client then asks the nurse, “how long to wear the bag before changing it”. The nurse should tell the client which of the following?
A. "You should change the bag every evening before bedtime." B. "You can wear the bag for about 4 to 7 days." C. "The bag is changed only when it leaks" D. "It depends on your activity level and your diet."
B. "You can wear the bag for about 4 to 7 days."
After having a colostomy surgically placed for colon cancer, discharge planning for home care would include teaching about the ostomy. What information should the nurse include in the teaching?
A. There is nothing that can be done if the bag is odorous. B. The client does not need to use the ostomy bag when having sexual intercourse. C. Instruct the client to report redness, swelling, fever, or pain at the site immediately to the provider because these can be signs of infection. D. The client can order ostomy supplies from their provider.
C. Instruct the client to report redness, swelling, fever, or pain at the site immediately to the provider
The patient being discharged soon is using the teach back method to show you how he will change the ostomy bag when it is necessary. What first 5 steps show the nurse that teaching was effective?
A. Gather necessary supplies, wash hands with soap and water, press skin around stoma and remove seal from skin, remove old pouch and place in proper waste receptacle, clean skin around stoma area with soap and water and tap dry with clean linen B. Use hand sanitizer, gather necessary supplies, press skin around stoma and remove seal from skin, remove old pouch and place in proper waste receptacle, clean skin around stoma area with soap and water and tap dry with clean linen. C. Wash hands with soap and water, gather necessary supplies, pull bag away from stoma and remove seal from skin, remove old pouch and clean bag to save for use after cleaning the stoma area, clean skin around stoma area with soap and water and tap dry with clean linen D. Gather necessary supplies, press skin around stoma and remove seal from skin, remove old pouch and place in proper waste receptacle, wash hands with soap and water, clean skin around stoma area with soap and water and tap dry with toilet paper.
A. Gather necessary supplies, wash hands with soap and water, press skin around stoma and remove seal from skin, remove old pouch and place in proper waste receptacle, clean skin around stoma area with soap and water and tap dry with clean linen
What is the most efficient method to preventing pressure injuries during the hospitalization period?
A. Turning the patient every 2 hours B. Placing the patient on a pressure redistribution bed C. Providing a daily bath D. Encouraging patient to reposition themselves
A. Turning the patient every 2 hours
How many pillows have proven to be best practice when repositioning a patient to aid in the prevention of pressure injuries?
A. The use of 3 pillows is best practice for repositioning B. The use of 5 pillows is best practice for repositioning C. The use of 7 pillows is best practice for repositioning D. Number of pillows recommended is not listed
B. The use of 5 pillows is best practice for repositioning
You are working as a nurse on the MTSU and are assigned four clients. Which client is at the highest risk for developing a pressure injury?
A. 29 year old female who is in the hospital recovering from a c-section B. 78 year old male client who returned from a hip replacement surgery 8 hours ago and is incontinent C. 70 year old female client who recently returned to her room from upper endoscopy, and ambulates independently. D. 15 year old who presented to the emergency department with a diagnosis of asthma exacerbation
B. 78 year old male client who returned from a hip replacement surgery 8 hours ago and is incontinent
Which method of verifying gastric tube placement after x-ray confirmation is preferred based on the clinical guideline?
A. Gastric lipase testing B. Carbon dioxide detection C. Aspiration D. Auscultation
C. Aspiration
When assessing aspirate as a conjunctive method to verifying gastric tube placement, all of the following biochemical markers were assessed EXCEPT: A. pH B. Pepsin C. Bilirubin D. Bradykinin
D. Bradykinin
Which of the following are reasons why alternative bedside options for verifying GT placement are continuing to be used rather than the gold standard – Radiographic examination (X-ray)? Select all that apply.
A. Alternative options such as auscultation has a decreased cost B. Some alternative options can be performed much faster C. The alternative options are much more accurate at verifying placement D. The alternative options allow the HCP’s to avoid radiation exposure
A. Alternative options such as auscultation has a decreased cost B. Some alternative options can be performed much faster D. The alternative options allow the HCP’s to avoid radiation exposure
When a child is entering the OR one parent is allowed but is required to watch videos prior to the invasive procedure. What is the reasoning for the video?
A. Understand safety in the OR B. Acknowledge any concerns C. Watch the procedure to know what to expect D. Learn complications
B. Acknowledge any concerns
There is evidence to support that there can be positive/negative effects on patients during invasive procedures if there is the presence of a family member. Which of the following is most important to assess with the family and patient before the procedure? A. Discharge planning and implementation B. Abiding by infection control after the procedure C. Finalized decisions are communicated between family, patient, and provider D. What type of food the patient wants on their meal tray post-procedure
C. Finalized decisions are communicated between family, patient, and provider
In what way(s) does having a parent present during an invasive procedure relieve stressors for the adolescent patient? (Select all that apply)
A. Increases patient satisfaction and ability to cope B. Allows parent to hold patient during the invasive procedure C. Stops patient from crying and feeling overwhelmed D. Made patients more comfortable and had a positive impact on care
A. Increases patient satisfaction and ability to cope D. Made patients more comfortable and had a positive impact on care
A hospital facility implements a falls risk bundle upon admission to prevent falls during the hospital stay. Which patient is most likely to receive the bundle?
A. Patient who is 23 years old complaining of dizziness that has lasted for several days. B. Patient who is 72 years old presenting with an unsteady gait and a previous history of falls. C. Patient who is 45 years old referred for an eye exam relating to impaired vision. D. Patient who is 60 years old with concerns of developing dementia due to a family history.
B. Patient who is 72 years old presenting with an unsteady gait and a previous history of falls.
When should a patient be reassessed for falls risk? (Select all that apply)
A. There is a change in the patient’s condition B. There is a change in medicationC. Immediately after a fall D. Each shift for high-risk patients
A. There is a change in the patient’s condition B. There is a change in medicationC. Immediately after a fall D. Each shift for high-risk patients
What are some of the interventions you may include in a patient’s individualized care plan?
A. Hourly rounding to assess needs of the patient B. Communicate high risk to other care givers when handing-off C. Engage the patient and family in education regarding the risk of falls and how to prevent falls D. All of the above
D. All of the above
Which of the following does the nurse recognize as the most important component of the oral care process when providing oral care?
A. Selection of solution used B. Using a mouthwash C. A thorough mechanical cleaning D. Applying a moisturizer to lips
C. A thorough mechanical cleaning
The nurse is caring for an unconscious patient who receives total care. In order to ensure patient safety, what should the nurse do before starting oral care?
A. Assess gag reflex B. Assess ability to swallow C. Placing the patient supine D. Inspecting the oral cavity
A. Assess gag reflex
A student nurse is explaining to her preceptor the importance of frequent oral care. Which statement by the student demonstrates accurate teaching?
A. "Contracting ventilator associated pneumonia has been shown to prolong hospital stays and can lead to an increased risk for morbidity" B. "Removing plaque through toothbrushing has been proven effective at ridding the oral mucosa of potentially pathogenic bacteria" C. "Oral care alone in addition to using a chlorohexidine rinse routinely is proven to decrease the incidence of ventilator associate infections" D. "Routine oral care decreases the risk for aspirating oral secretions containing infectious bacteria" E. All of the above statements are correct.
E. All of the above statements are correct.
Evidence shows that tobacco use during pregnancy can lead to a multitude of teratogenic effects to the fetus, leading to later complications in life. What is an inappropriate long-term effect for the nurse to include during education at a prenatal check-up?
A. Sudden Infant Death Syndrome B. Increase in levels of norepinephrine and epinephrine C. Infantile Colic D. Low Birth Weight
B. Increase in levels of norepinephrine and epinephrine
A patient comes into the OBGYN clinic for her prenatal visit. She expresses that she has a history of smoking one pack of cigarettes daily but is aware of the teratogenic effects on the baby. She is interested in finding an alternative therapy that is less harmful to the baby. What gold standard alternative therapy would you expect the provider to order?
A. Reduce the number of cigarettes smoked daily B. Chewing tobacco C. Nicotine patch D. Vaping
C. Nicotine patch
A patient comes into the clinic for her first prenatal visit, which of the following statements by the patient would warrant further education about tobacco cessation in pregnancy by the nurse?
A. "Bupropion may be used as a tobacco cessation alternative." B. "My baby is protected by the placenta, so I can continue to smoke." C. "Smoking cigarettes during pregnancy may lead to low birth weight, infantile colic and sudden infant death syndrome." D. "I will switch to the nicotine patch for a safer alternative than smoking cigarettes.”
B. "My baby is protected by the placenta, so I can continue to smoke."
A patient in the ICU has a documented Stage 3 pressure ulcer on the sacrum. The primary care nurse goes to assess the dressing and site. What should the assessment and documentation of the pressure ulcer include?
A. Presence or absence of exudate including description and amount B. Location of pressure ulcer including length, width and depth C. Presence or absence of tunneling including number and depth of each D. Presence or absence of granulation, necrosis, or epithelialization of tissue E. All of the above
E. All of the above
Using the image provided, identify the stage of the pressure injury: A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury E. Unstageable pressure injury
C. Stage 3 pressure injury
A patient returns from the O.R. and the nurse finds a pressure injury located on the heel of the right foot due to the positioning of the patient during surgery. What should the nurse do next?
A. Confront the surgeon about the pressure injury. We cannot have more patients develop this type of injury during their operations. B. Document that the injury had developed before the surgery or hospitalization took place – you cannot have your hospital lose financial compensation. C. Discuss with the patient on ways to care for the injury at home including proper nutrition, frequent bandage changes, and ointment application. D. Discover what stage the pressure injury is and document that it was likely developed during the surgery with details regarding pre and post-surgery skin assessments.
D. Discover what stage the pressure injury is and document that it was likely developed during the surgery with details regarding pre and post-surgery skin assessments.
An incident occurs at work where you, a nurse, overhear another nurse verbally harassing a care partner because a patient was not turned at the correct time. The volume of the argument begins to increase, and it seems as if the nurse may get physically violent. Which of the following actions, if done by the health service organization prior, would be recommended to provide the witnessing nurse with tools in order to prevent the incident from escalating?
A. Provide training to health workers on the chain of command to follow after the incident. B. Provide training to health workers on de-escalation techniques, including communication and redirection strategies, to prevent and/or reduce violent incidents within their organizations. C. Establish guidelines that encourage the witnessing nurse to step between the nurse and care partner to create a barrier and de-escalate the situation. D. Encourage anyone witnessing a violent situation to restrain the violent person and call for a supervisor
B. Provide training to health workers on de-escalation techniques, including communication and redirection strategies, to prevent and/or reduce violent incidents within their organizations.
Health Organizations should establish an implementation plan for integrating a violence risk assessment tool for persons that include: (Select all apply)
A. Selection of a risk assessment tool that is applicable to the clinical population and setting B. Several tools that can be used for a broad population C. Education and training on the chosen tool for all health workers who provide direct care D. Education on what steps to follow after a violent event has taken place
A. Selection of a risk assessment tool that is applicable to the clinical population and setting C. Education and training on the chosen tool for all health workers who provide direct care
Which of the following can be identified as protective and security measures against violence in the healthcare setting? (Select all that apply.)
A. Equipment to protect against violent behaviors, and a standardized approach for deciding what, when, and how to use these. B. Environmental security measures, including locked doors, closed-circuit cameras and alarm systems. C. Set of physical restraints placed in each patient room D. Documentation and communication of a person’s previous incident(s) of violence including formal reporting systems that are simple to use.
A. Equipment to protect against violent behaviors, and a standardized approach for deciding what, when, and how to use these. B. Environmental security measures, including locked doors, closed-circuit cameras and alarm systems. D. Documentation and communication of a person’s previous incident(s) of violence including formal reporting systems that are simple to use.
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