Nokea
The nurse is part of a committee tasked with reducing medical errors in the nursing unit. Which of the following recommendations should the nurse make to the committee? Select all that apply.
- A. Increase the number of verbal orders given from primary healthcare providers
- B. Nurse-to-nurse bedside handoff reporting
- C. Handoff reporting using the ISBAR framework
- D. Ensure staff are taking uninterrupted breaks
- E. Increase the lighting around the medication dispensing machines
Correct Answer: B,C,D,E
Rationale: Bedside handoffs, ISBAR framework, breaks, and better lighting reduce errors. Verbal orders increase error risk.
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The nurse in the emergency department (ED) is caring for a child with erythema infectiosum (Fifth disease). Which transmission-based precautions should the nurse implement?
- A. Standard
- B. Droplet
- C. Contact
- D. Airborne
Correct Answer: A
Rationale: Erythema infectiosum is typically non-infectious once the rash appears, requiring only standard precautions.
The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure?
- A. Blood pressure
- B. End-tidal carbon dioxide [ETCO2] level
- C. Respiratory rate
- D. Blood glucose
- E. Oxygen saturation
Correct Answer: A,B,C,E
Rationale: During moderate sedation, monitoring blood pressure, end-tidal CO2, respiratory rate, and oxygen saturation is essential to assess cardiovascular and respiratory status, ensuring patient safety. Blood glucose is not routinely monitored unless indicated by the patient’s condition.
The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside?
- A. Overhead trapeze
- B. Abduction pillow
- C. Transfer board
- D. Continuous passive motion (CPM)
Correct Answer: A
Rationale: An overhead trapeze assists with safe repositioning and mobility post-lumbar spinal fusion, reducing strain on the surgical site. Abduction pillows are used for hip surgeries, transfer boards aid general transfers, and CPM is for joint surgeries, not spinal fusion.
Upon entering a client's room, the nurse finds the client lying on the floor. What is the first action the nurse should implement?
- A. Call for help to get the client back in bed
- B. Assist the client back to bed
- C. Establish if the client is responsive
- D. Ask the client what happened
Correct Answer: C
Rationale: Establishing responsiveness ensures the client’s immediate safety and guides further actions. Other steps follow after assessing the client’s condition.
The nurse teaches a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up?
- A. I will need to bathe with chlorhexidine gluconate solution (CHG) the night before surgery to prevent an infection
- B. I will need to take deep breaths and cough hourly
- C. I will have to attend physical therapy sessions following my surgery
- D. I will be prescribed an anticoagulant and need to take it with a sip of water before the surgery
Correct Answer: D
Rationale: Taking an anticoagulant with a sip of water before surgery is incorrect, as clients are typically NPO, and anticoagulants like enoxaparin are administered post-operatively to prevent thromboembolism. The other statements are correct regarding infection prevention, respiratory exercises, and physical therapy.