RN Safe and Effective Care Environment 2

Question 1

A nurse is assigned four patients. Which patient should the nurse assess first?

Accepted Answer

A post-operative patient reporting sudden onset of chest pain and shortness of breath 6 hours after surgery

Answer

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:

Accepted Answer

Assess the patient, notify the physician and charge nurse, document accurately, and complete an incident report

Answer

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:

Accepted Answer

Delay the procedure and notify the surgeon to correct the consent before proceeding

Answer

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)?

Accepted Answer

Measuring and recording urine output for a stable patient

Answer

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:

Accepted Answer

15 minutes for behavioral restraints

Answer

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.

RN - Registered Nurse Practice Test

RN - Registered Nurse Practice Test

RN Safe and Effective Care Environment 2