Week 1 Lab Content (NUR 314)

EAQs pertaining to clinical skill content covered in the first week.

How does soap work?

Emulsifies fat and oil so that dirt and microorganisms can be mechanically removed

What is the primary purpose of appropriate hand hygiene?

To prevent or control the transmission of infectious microorganisms from any source

In which situation would it be appropriate for the nurse to use an antiseptic hand rub to perform hand hygiene?

The nurse’s hands are not visibly soiled.

The nurse is discussing the guidelines for proper hand hygiene with nursing assistive personnel (NAP). Which statement made by NAP requires follow-up by the nurse?

"To prevent dry skin, I avoid using soap and water."

Which patient is at the greatest risk for hospital-acquired infection (HAI)?

A middle-age female patient receiving chemotherapy for lung cancer

When preparing to clean a patient’s dentures using the sink, the nurse first protects the dentures by doing what?

Padding the sink basin with a washcloth

What would the nurse instruct nursing assistive personnel (NAP) to report when performing denture care for a patient?

The appearance of any cracks in the dentures

Under what circumstances would the nurse assume responsibility for providing denture care for a patient?

The patient is unable to care for the dentures on his or her own.

A patient tells the nurse that at home he cleans his dentures after every meal and before going to bed. When would denture care be planned for this patient while hospitalized?

After every meal and before going to bed

A patient has removed her dentures and placed them on the bedside stand. What would the nurse do to protect the patient’s dentures?

Obtain a denture cup, label it with the patient’s name, and store the dentures in a safe place.

When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what?

Assessing the patient’s gag reflex

What is the primary reason an unconscious patient is placed in the side-lying position when mouth care is provided?

To reduce the risk of aspiration

The nurse is planning to insert an oral airway into an unconscious patient before performing mouth care. In which direction is the airway initially inserted into the patient’s mouth?

Upside down, or with the curve facing up

When brushing the teeth of an unconscious patient, why is the toothbrush held so that its bristles are at a 45-degree angle to the gum line?

To allow the bristles to reach beneath the gum line

To allow the bristles to reach beneath the gum line

Stimulating the gag reflex

The nurse has delegated to nursing assistive personnel (NAP) the skill of assisting with a bedpan for a patient who has had discomfort when walking to the bathroom. Which statement made by the NAP requires the nurse’s follow-up?

“If I can get someone to help, I’ll walk her to the bathroom.”

A patient with a nasogastric tube, an intravenous infusion line, and an indwelling urinary catheter needs to be placed on the bedpan. Which action would the nurse take first to ensure the patient’s safety?

Obtain help to place the patient on the bedpan.

A dependent, confused patient is being given a bedpan. How can the nurse best ensure the patient’s safety?

Raise the side rails on the bed before leaving the room.

The nurse is assisting with a bedpan for a patient who had knee surgery 24 hours ago. What is the best way for the nurse to maximize comfort while the patient uses the bedpan?

Elevate the head of the bed to between 30 and 60 degrees.

After assisting with a bedpan, the nurse notes that the patient’s stool is streaked with bright-red blood. What would the nurse do first?

Check the medical record to see if the patient has a history of blood in the stool.

The nurse is helping a patient with hemiparesis take a few steps. A gait belt has been applied. The patient is using a cane. Where should the nurse stand in relation to the patient?

On the patient’s weak side

The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk?

Ask the patient how far she would like to go.

The nurse has applied a gait belt to a postoperative patient to facilitate ambulation. Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse’s initial response?

Slowly lower the patient to the floor.

The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to nursing assistive personnel (NAP). Which statement made by NAP requires the nurse to follow up?

“I will use the under-axillae technique to help him up to a standing position.”

The nurse is ambulating a patient with a gait belt when he says he feels sick to his stomach. What would the nurse do?

Return the patient to the bed or chair (whichever is closer).

Which personal protective equipment (PPE) will the nurse wear if there is a risk of a blood splash when caring for a patient?

Gown, gloves, mask, and eye protection

What will the nurse do first when preparing to apply personal protective equipment (PPE) before caring for a patient in isolation?

Perform hand hygiene

The nurse is discussing the guidelines for proper use of PPE by nursing assistive personnel (NAP). Which statement made by the NAP requires follow-up by the nurse?

"I really dislike wearing a mask, so it's the first thing I take off."

When removing a gown worn as personal protective equipment (PPE) while caring for a patient in isolation, why does the nurse avoid touching the outside of the gown?

To prevent touching contaminated material with unprotected hands

When delegating patient care that requires nursing assistive personnel (NAP) to use personal protective equipment (PPE), it is necessary for the nurse to do what first?

Review the patient's need for a specific isolation precaution

The nurse is assisting a patient with a tub bath. After the patient has been safely positioned in the tub, he tells the nurse, "I'll call you when I’m done." What is the nurse's best response?

"Well, I'll check back with you in about 5 minutes to see if you need anything."

The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care?

Dorsal recumbent

As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority?

Assess the patient's ability to perform proper perineal care.

How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?

By cleansing the patient's labia from the pubic area toward the rectum.

The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure the NAP's safety while performing this care?

Wear clean gloves.

Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter?

Wear clean gloves during care.

A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response?

"When did you start experiencing the pain?"

What is the primary reason for performing perineal care on a male patient with incontinence?

To reduce the risk of skin breakdown in the patient's genital and perineal area

The nurse has washed a patient’s arms. Which area should the nurse wash next?

Hand

A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient's safety?

Make sure the call light is within the patient’s reach.

Which patient should not have his or her feet soaked during a complete bed bath?

A patient with diabetes mellitus

The nurse is bathing a patient who is unconscious. What should the nurse do to ensure safe care of the patient's eyes?

Use eye patches or shields taped in place.

The nurse is preparing to give a patient a bath using a disposable bed bath product. What should the nurse do first?

Check the patient’s record for restrictions to mobility.

What can the nurse do to keep the patient from becoming chilled while receiving a bath with a disposable bed bath product?

Cover the patient with a bath towel.

The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer?

Two

The nurse is preparing to move a patient from the bed to a stretcher. What will the nurse do first?

Make sure the bed brakes are locked.

When turning a patient to place a slide board, where do the assistants stand?

At the side of the bed to which the patient will be turned

The nurse and the assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move?

Push and guide the slide board.

After moving a patient from the bed to a stretcher, what will the nurse do next?

Raise the stretcher’s side rails.

When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first?

Assess the patient's physiological capacity to transfer.

Which instruction would the nurse give a patient who is able to assist with transfer from a bed to a wheelchair using a transfer belt?

"Please push down onto the mattress with both hands and stand when I count to three."

A patient lying supine in bed is being transferred to a wheelchair using a transfer belt. Which action would the nurse perform just before moving the patient to the side of the bed?

Raise the head of the bed 30 degrees.

The nurse is preparing to transfer a patient with left-sided weakness from the bed to a wheelchair using a transfer belt. Which position would the nurse instruct the patient to assume?

Place your stronger leg forward and your weaker leg toward the back.

A patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair?

Lower the foot rests, and place the patient's feet on them.

When making a surgical bed with no patient present, at which time is it unnecessary to perform hand hygiene?

After disposing of soiled linen that is not visibly soiled.

A new nursing assistive personnel (NAP) is making a surgical bed for a patient who is having abdominal surgery. Where will you instruct the NAP to place the waterproof pad on this bed?

Over the bottom sheet

For a surgical bed, why is the linen formed into a triangle and fanfolded away from the side on which the patient will be transferred?

For a surgical bed, why is the linen formed into a triangle and fanfolded away from the side on which the patient will be transferred?

When making a surgical bed, why does the nurse avoid shaking the linen being removed from the bed?

To prevent contamination to the environment and the nurse's uniform

The nurse is preparing to make an occupied bed for a patient who is on aspiration precautions. What will the nurse do to ensure the safety of this patient during the bed change?

Keep the head of the bed no lower than a 30-degree angle.

The nurse is directing nursing assistive personnel (NAP) to make an occupied bed. What will the nurse say to minimize the risk of disease transmission to staff and patient during the bed change?

"You'll need to apply Standard Precautions during this task."

Which action ensures that a patient will not have unnecessary pain during a linen change?

Administer a prescribed analgesic 30 to 60 minutes before the bed change if needed.

The nurse is changing the bed linen of a patient on bed rest. When the nurse is ready to make the other side of the bed, what will the nurse do before having the patient turn onto the side that has already been made?

Raise the side rails

What will the nurse do right after placing a clean topsheet on the patient?

Remove the bath blanket.

When preparing to move a patient in bed, what will the nurse do first?

Assess the patient's ability to help with moving.

When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety?

Flex the hips and knees.

A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers?

At least three

In which position will the nurse place the patient to move him or her up in bed?

Supine with the head of the bed flat

A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient?

Roll the patient from side to side, and place the device under the drawsheet.

When positioning a hemiplegic patient in the supported Fowler's position, what is the primary reason a trochanter roll is placed alongside the patient's legs?

To reduce the risk of contracture

To which position would the nurse assist the patient who is experiencing difficulty with breathing?

Fowler’s position

When repositioning a patient, what can the nurse do to prevent the patient's hips from rolling outward?

Place sandbags along the legs.

The nurse is preparing to move a patient with hemiplegia into the prone position. What action should the nurse take when rolling the patient onto her side?

Place a pillow on the abdomen.

The nurse is preparing to logroll a patient in bed. Why are two assistants needed on the side toward which the patient is being turned?

To roll the patient as a unit

The nurse who is preparing to make an unoccupied bed should do what to ensure his or her personal safety?

Place the bed at a comfortable working height.

The nurse is preparing to change the soiled linen of a patient's unoccupied bed. Which precaution minimizes the risk of transmitting microorganisms?

Perform hand hygiene and apply clean gloves.

What would the nurse instruct the nursing assistive personnel (NAP) to do before making an unoccupied bed if the mattress is soiled?

Wipe off moisture with antiseptic solution, and dry thoroughly.

The nurse is reviewing placement of an unfitted bottom sheet with nursing assistive personnel (NAP) assigned to make an unoccupied bed. What should the nurse include in this teaching?

The lower hem of the sheet should lie seam down and even with the bottom edge of the mattress.

When making an unoccupied bed, where would the nurse place a waterproof pad?

Over the bottom sheet.

When preparing for safe patient transfer using a hydraulic lift, the nurse performs which action first?

Assesses the patient for weakness, dizziness, or postural hypotension

Which position is used when applying the sling to transfer a patient from the bed to a chair with a hydraulic lift?

Supine

Which action would decrease a patient’s pain before a transfer with a hydraulic lift?

Administer a prescribed analgesic 30 to 60 minutes before the transfer.

What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift?

Have the patient cross the arms over the chest.

When using a hydraulic lift to transfer a patient from the bed to a chair, when does the nurse turn off the check valve?

As soon as the patient has been placed in the chair

Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours?

To check the skin integrity and range of motion of the wrist

What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint?

“Tell me if the skin under the restraint becomes abraded or raw.”

The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse’s best response when the patient’s wife says, “I don’t like him being tied down in the bed?”

“We will try all other alternatives before using physical restraints.”

When a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient’s gown bunched around the patient’s chest and the patient asking for help. What would the NAP do?

Untie the restraint and smooth the patient’s gown

When preparing to assist a patient with a gown change, the nurse will promote infection control by doing what after performing hand hygiene?

Applying clean gloves

When changing the soiled gown of a patient with left-sided paralysis, what will the nurse do first?

Remove the sleeve from the stronger arm

When changing a patient’s gown, the nurse will place the bed in which position?

A height that allows the patient full range of motion

What will the nurse do when a gown change is needed for a patient who is receiving intravenous fluids delivered by a pump?

Pause the infusion by pressing the sensor on the pump

Why must the nurse check the flow rate after changing the gown of a patient who is receiving intravenous fluids infused by gravity?

To check whether manipulation of the intravenous container and tubing has disrupted the flow rate

When preparing to assist a patient with hair care, why does the nurse first check the patient’s scalp for inflammation?

To ensure that the care can be performed without injuring the scalp

What is the primary reason the nurse encourages the patient to participate in hair care?

To encourage the patient’s sense of independence

What is the purpose of parting the patient’s hair into sections?

To make brushing and combing more effective

For which of the following patients would it be necessary to use a disposable shampoo cap, rather than a shampoo board?

A young man who has sustained a fracture of the upper spine in a football game.

Which action should be avoided when providing hair care for a bed-bound patient with a history of dizziness?

Placing the neck in a hyperextended position during the shampoo process.

For which patient would the nurse most likely ask for a podiatrist consult for nail care?

A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot.

Why would the nurse plan to perform foot care for a patient with peripheral vascular disease (PVD), rather than delegate this activity to nursing assistive personnel (NAP)?

The patient’s elevated risk of infection makes it unsafe for NAP to perform the care.

Which action would the nurse encourage an older adult with foot problems to take at home?

Wear socks made of natural fibers.