Nokea
The Joint Commission on the Accreditation of Healthcare Organizations mandates standardized 'hand off' change of shift reporting. Which of the following is a standardized 'hand off' change of shift reporting system that you may want to consider for implementation on your nursing care unit?
- A. The Four P's
- B. UBAR
- C. ISBAR
- D. MAUMAR
Correct Answer: C
Rationale: ISBAR is a standardized hand-off reporting system (Introduction, Situation, Background, Assessment, Recommendation) recommended by The Joint Commission for effective communication during shift changes.
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A client with a history of chronic kidney disease is admitted with anemia. The nurse should expect to administer which of the following medications?
- A. Epoetin alfa (Epogen).
- B. Ferrous sulfate.
- C. Vitamin B12.
- D. Folic acid.
Correct Answer: A
Rationale: Epoetin alfa stimulates red blood cell production in chronic kidney disease-related anemia.
The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure?
- A. Remove the inner cannula every 2 hours for cleaning.
- B. Secure the tracheostomy ties with a square knot.
- C. Use cut gauze under the neck plate to protect the skin.
- D. Suction the inner cannula on completion of the procedure.
Correct Answer: B
Rationale: Securing tracheostomy ties with a square knot ensures stability and safety. Frequent cannula removal is unnecessary, cut gauze may fray, and suctioning is done as needed, not routinely.
The nurse is preparing to perform a Mantoux tuberculin skin test. Which interventions apply to the administration of this test? Select all that apply.
- A. Explain the procedure to the client.
- B. Obtain a 3-mL syringe with a 1/2-inch needle for the injection.
- C. Mark the test area to locate it for reading 48 to 72 hours after injection.
- D. Bunch up the skin and insert the needle with the needle bevel facing downward.
- E. Cleanse the injection site on the lower dorsal surface of the forearm with alcohol and allow it to dry.
- F. Ask the client about a history of receiving a positive purified protein derivative (PPD) reaction.
Correct Answer: A,C,E,F
Rationale: The nurse should always explain the procedure to the client and then assess him or her for a history of a PPD reaction. The test should not be administered if the client has such a history. The nurse should use a tuberculin syringe (not a 3-mL syringe) with a 1/2-inch 26- or 27-gauge needle. The injection site on the lower dorsal surface of the forearm is cleansed with alcohol and allowed to dry. The skin is stretched taut, and 0.1 mL of solution containing 0.5 tuberculin units of PPD is injected. The injection is made just under the surface of the skin with the needle bevel facing upward to provide a discrete elevation of the skin (a wheal) 6 to 10 mm in diameter. The test area is marked to locate it for reading and the test area is read 48 to 72 hours after injection.
A client with a history of peptic ulcer disease is prescribed ranitidine (Zantac). The nurse should explain that this medication works by:
- A. Neutralizing gastric acid.
- B. Reducing gastric acid secretion.
- C. Coating the stomach lining.
- D. Increasing gastric motility.
Correct Answer: B
Rationale: Ranitidine, an H2-receptor blocker, reduces gastric acid secretion, helping to heal peptic ulcers.
The nurse notices drops of a liquid on the hallway floor of a health care facility. The nurse should do which of the following first?
- A. Place paper towels over the drops of liquid.
- B. Don clean gloves and wipe up the drops of liquid.
- C. Post 'wet floor' signs around the area.
- D. Call the Environmental Services Department.
Correct Answer: C
Rationale: Posting 'wet floor' signs first ensures immediate safety by alerting others to the hazard, preventing slips. Then, the nurse can proceed with cleanup or notify appropriate personnel.