Nokea
A patient has been restrained to prevent him from pulling out his nasogastric tube. You assign a UAP to check on the patient. What directions will you give?
- A. Check on him every 30 minutes and release him every 2 hours. Don't forget to document all your checks on the flow sheet.'
- B. Look in on the patient from the doorway every 2 hours. Make sure the tube is still in place.'
- C. Just to be extra careful, check on him every hour and ask if he needs to go to the bathroom.'
- D. Release him from the restraints every 30 minutes and document that you have done so.'
Correct Answer: A
Rationale: Restraints require frequent checks (every 30 minutes) and release every 2 hours for repositioning, toileting, and skin assessment, with documentation to ensure compliance with safety protocols.
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To use proper body mechanics, you need to be most concerned about:
- A. your center of gravity, your base of support, and using your leg muscles.
- B. obtaining lifting equipment, obtaining assistance, and keeping your feet apart.
- C. your center of support, base of gravity, and the position of your back.
- D. finding ways to avoid lifting and wearing a brace to protect your back.
Correct Answer: A
Rationale: Proper body mechanics involve maintaining a stable center of gravity, a wide base of support, and using leg muscles to lift, minimizing strain on the back.
While rinsing a used surgical instrument in a disinfectant called Cidex, some of the Cidex splashes on your lips and nose. Your first action is to:
- A. rinse your mouth and nose immediately with running water.
- B. consult the SDS for Cidex to know what actions to take.
- C. induce vomiting in case you accidentally swallowed any of the chemical.
- D. wash the area immediately with surgical soap and water.
Correct Answer: A
Rationale: Immediate rinsing with water removes the chemical from mucous membranes, reducing potential harm before consulting the Safety Data Sheet (SDS).
You walk into a patient's room and find a fire involving the trash can and curtains. What will you do first?
- A. Use the call light to tell the unit clerk to activate a Code Red.
- B. Step into the hall and call for help, announcing a fire in this room.
- C. Use the telephone in the room to notify the fire department using a special code.
- D. Remove the patient from the room to a safer area of the hospital.
Correct Answer: D
Rationale: The RACE acronym prioritizes rescuing patients from immediate danger first to ensure their safety before addressing the fire.
A newly admitted patient may be at risk for falls. While the patient is in the bathroom changing into a hospital gown, the admitting nurse would be most concerned about:
- A. ordering soft device bolsters for the bed.
- B. arranging for a bed monitor to be placed on the bed.
- C. staying near the bathroom to help the patient back to bed.
- D. determining whether to ask the doctor for an order for restraints.
Correct Answer: C
Rationale: Staying near the bathroom ensures immediate assistance if the patient becomes unsteady, directly addressing the immediate fall risk during a vulnerable activity.
During clinical, you think you see a staff nurse swallow a narcotic medicine she signed out for a patient. What will you do?
- A. Ask the staff nurse if she just swallowed that pill.
- B. Say nothing and watch the nurse to see if she acts different later.
- C. Tell a fellow student at break so you can both watch the nurse.
- D. Confidentially tell your instructor what you thought you saw.
Correct Answer: D
Rationale: Reporting suspected diversion to an instructor ensures proper investigation while maintaining confidentiality and adhering to ethical standards.