Safe and Effective Care Environment 2 — Questions and Answers
Question 1: A nurse notices a colleague administered the wrong dose of insulin to a client. The client is currently asymptomatic. What is the nurse's first action?
- Complete the incident report before doing anything else
- Assess the client for adverse effects from the insulin overdose (Correct answer)
- Confront the colleague about the error in front of the client
- Administer orange juice to all clients on the unit as a precaution
Correct answer: Assess the client for adverse effects from the insulin overdose
When a medication error occurs, the nurse's first action is to assess the client for any adverse effects, even if the client appears asymptomatic. An insulin overdose can cause hypoglycemia that may develop over time. After assessing the client, the nurse notifies the provider and the charge nurse, documents the event, and completes an incident/variance report. Client safety and assessment always come before documentation.
Question 2: A nurse is preparing to administer a blood transfusion. Which action by the nurse best prevents a transfusion reaction?
- Prime the IV tubing with normal saline only
- Have two licensed nurses verify client identity and blood compatibility at the bedside (Correct answer)
- Pre-medicate all clients with diphenhydramine before every transfusion
- Hang the blood product within 4 hours of removal from the blood bank
Correct answer: Have two licensed nurses verify client identity and blood compatibility at the bedside
Verifying blood compatibility at the bedside with two licensed nurses — checking the client's identity (name, date of birth, medical record number) against the blood product label and blood bank crossmatch report — is the most critical safety step to prevent an acute hemolytic transfusion reaction caused by ABO incompatibility. This two-nurse verification is the single most important error-prevention action before transfusion.
Question 3: A nurse is working on a medical-surgical unit when a fire alarm activates. What is the correct sequence of actions using the RACE acronym?
- Rescue, Alarm, Confine, Extinguish/Evacuate (Correct answer)
- Alarm, Rescue, Extinguish, Confine
- Run, Alert, Call, Evacuate
- Rescue, Alert all staff, Call 911, Escape
Correct answer: Rescue, Alarm, Confine, Extinguish/Evacuate
RACE stands for Rescue, Alarm, Confine, Extinguish/Evacuate. First: Rescue — move clients in immediate danger. Second: Alarm — activate the fire alarm if not already done. Third: Confine — close doors and windows to contain the fire and smoke. Fourth: Extinguish the fire if it is small and safe to do so, or Evacuate if not. This sequence prioritizes human life first, then containment, then suppression.
Question 4: A client on a medical-surgical unit is placed on Contact Precautions for C. difficile infection. Which PPE should the nurse don before entering the room?
- Gloves only — gowns are not required for C. difficile
- N95 respirator, gloves, and gown
- Gloves and gown, with hand washing using soap and water (Correct answer)
- Surgical mask and gloves, using alcohol-based hand sanitizer
Correct answer: Gloves and gown, with hand washing using soap and water
C. difficile (C. diff) requires Contact Precautions. The nurse must wear gloves and a gown before entering the room to prevent environmental contamination. Crucially, alcohol-based hand sanitizers do NOT kill C. diff spores — soap and water handwashing is required. A mask is not routinely required for C. diff unless the client has co-existing airborne or droplet precautions.
Question 5: A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is appropriate for the nurse to delegate?
- Assessing a client's pain level and response to analgesics
- Teaching a client how to use an incentive spirometer
- Measuring and recording vital signs on a stable post-op client (Correct answer)
- Developing a plan of care for a newly admitted client
Correct answer: Measuring and recording vital signs on a stable post-op client
Delegation must follow the Five Rights: right task, right circumstance, right person, right direction, and right supervision. Measuring and recording vital signs on a stable client is within the UAP's scope of practice and training. Assessment, nursing judgment, teaching, and evaluation of interventions cannot be delegated — these require a licensed nurse's professional judgment.
Question 6: A nurse discovers a client has been receiving the wrong IV fluid for the past two hours. The client is stable. After stopping the incorrect fluid, what should the nurse do next?
- Complete the incident report before calling the provider
- Notify the provider of the error and current client status (Correct answer)
- Ask the charge nurse to handle the situation
- Document the error in the chart and monitor the client for 1 hour
Correct answer: Notify the provider of the error and current client status
After stopping the incorrect IV fluid and assessing the client (already confirmed stable), the nurse's next step is to notify the provider so appropriate orders can be given — including restarting the correct IV fluid and any needed assessment or intervention. Only after addressing immediate client safety and provider notification does the nurse complete documentation and an incident report.
Safe and Effective Care Environment 2
A nurse notices a colleague administered the wrong dose of insulin to a client.
The client is currently asymptomatic.
What is the nurse's first action?