1.Easy
To which patients do standard precautions apply?
- AOnly patients with an open wound
- BAll patients, whether or not an infection is known
- COnly patients with a confirmed infection on a lab test
- DOnly patients in intensive care
2.Easy
When a nurse receives a critical lab result by phone, what does “read-back” mean?
- AReading the result aloud to the patient straight away
- BReading the result to the next shift at handover
- CWaiting for the written report before doing anything
- DRepeating the result back to the caller to confirm it
3.Easy
In priority setting, an “expected” finding is one that:
- AAlways needs an immediate call to the rapid response team
- BFits the patient’s known condition or treatment
- CIs always inside the normal adult reference range
- DHas been predicted by the patient or the family
4.Medium
Which action helps prevent a catheter-associated urinary tract infection?
- AKeeping the drainage bag below the level of the bladder
- BDisconnecting the bag every shift to empty it
- CRaising the drainage bag above the bladder when walking
- DLeaving the catheter in place longer than needed
5.Medium
A patient has a reddened area on the sacrum that does not blanch when pressed. What is the priority action?
- ARelieve pressure on the area by changing position regularly
- BMassage the area firmly to improve the blood flow to the skin
- CKeep the patient lying on the back to protect the area
- DApply a heat pad to the area to increase circulation
6.Medium
A nurse teaches a patient who uses home oxygen. Which statement shows a need for further teaching?
- A“I will keep the oxygen away from the gas stove.”
- B“I will put up no-smoking signs at the front door and in my room.”
- C“My husband can smoke in my room if the window is open.”
- D“I will not use oil-based creams on my face.”
7.Hard
A trauma patient has an open leg fracture, absent breath sounds on one side, a trachea shifted to the other side and a falling blood pressure. Which problem is the priority?
- AThe suspected tension pneumothorax
- BThe open fracture of the leg
- CThe risk of wound infection
- DThe pain from the fracture
8.Hard
A day after a femur fracture, a young patient becomes confused and breathless, with small red spots on the chest. What should the nurse suspect?
- AAn allergic reaction to the cast
- BFat embolism syndrome
- CNormal pain after a fracture
- DAlcohol withdrawal
Answer key
- 1. B · All patients, whether or not an infection is known
- 2. D · Repeating the result back to the caller to confirm it
- 3. B · Fits the patient’s known condition or treatment
- 4. A · Keeping the drainage bag below the level of the bladder
- 5. A · Relieve pressure on the area by changing position regularly
- 6. C · “My husband can smoke in my room if the window is open.”
- 7. A · The suspected tension pneumothorax
- 8. B · Fat embolism syndrome
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