RN Safe and Effective Care Environment 2 — Questions and Answers
Question 1: A nurse is assigned four patients. Which patient should the nurse assess first?
- A patient with stable COPD requesting pain medication for mild discomfort
- A post-operative patient reporting sudden onset of chest pain and shortness of breath 6 hours after surgery (Correct answer)
- A patient with type 2 diabetes whose morning blood glucose is 180 mg/dL
- A patient scheduled for discharge who needs medication teaching
Correct answer: A post-operative patient reporting sudden onset of chest pain and shortness of breath 6 hours after surgery
Sudden chest pain and dyspnea in a post-operative patient may indicate pulmonary embolism, a life-threatening emergency requiring immediate assessment using ABCs.
Question 2: A nurse discovers a medication error was made by the previous shift nurse. The correct action is to:
- Speak with the nurse privately and decide together not to report it
- Assess the patient, notify the physician and charge nurse, document accurately, and complete an incident report (Correct answer)
- Only document the error in the chart and monitor the patient
- Report the nurse to the state board immediately without assessing the patient first
Correct answer: Assess the patient, notify the physician and charge nurse, document accurately, and complete an incident report
Patient safety requires immediate assessment and physician notification; transparent documentation and an incident report enable systems analysis to prevent future errors.
Question 3: A patient is scheduled for surgery on the left knee but the consent form reads 'right knee.' The nurse's correct action is:
- Proceed with surgery because the surgeon knows which knee is involved
- Delay the procedure and notify the surgeon to correct the consent before proceeding (Correct answer)
- Cross out 'right' and write 'left' on the consent form
- Ask the patient to initial the error on the consent form
Correct answer: Delay the procedure and notify the surgeon to correct the consent before proceeding
Surgical site errors are never events; the nurse must halt the procedure, notify the surgeon, and ensure the consent is corrected and resigned before proceeding per the Universal Protocol.
Question 4: Which nursing task is most appropriate to delegate to an unlicensed assistive personnel (UAP)?
- Assessing a patient's pain level and adjusting care
- Administering an oral medication to a stable patient
- Measuring and recording urine output for a stable patient (Correct answer)
- Performing a sterile wound dressing change
Correct answer: Measuring and recording urine output for a stable patient
Measuring and recording urine output is within the UAP's scope as it involves data collection from a stable patient; assessment, medication administration, and sterile procedures require nursing judgment.
Question 5: A patient in restraints must be reassessed at minimum every:
- 15 minutes for behavioral restraints (Correct answer)
- 4 hours for all types of restraints
- 8 hours for non-violent restraints
- 2 hours for all types of restraints
Correct answer: 15 minutes for behavioral restraints
CMS and Joint Commission require that patients in behavioral (violent) restraints be assessed every 15 minutes, while non-violent restraints require reassessment every 2 hours.
Question 6: A nurse administers the wrong dose of insulin to a patient. Which document should NOT be referenced in the patient's medical record?
- Nursing notes documenting the event and patient response
- The incident/occurrence report (Correct answer)
- The physician notification note
- The medication administration record correction
Correct answer: The incident/occurrence report
Incident reports are internal quality improvement tools and should never be referenced, attached, or mentioned in the patient's medical record, as they are protected documents.
RN Safe and Effective Care Environment 2
A nurse is assigned four patients.
Which patient should the nurse assess first?