Safe and Effective Care Environment 1 — Questions and Answers
Question 1: A nurse is receiving a client from the emergency department who has a history of MRSA. Which transmission-based precaution is required?
- Droplet precautions with a surgical mask and private room
- Airborne precautions with an N95 respirator and negative pressure room
- Contact precautions with gloves and gown for all client contact (Correct answer)
- Standard precautions only, as MRSA is not transmissible in the inpatient setting
Correct answer: Contact precautions with gloves and gown for all client contact
MRSA (methicillin-resistant Staphylococcus aureus) is transmitted by direct and indirect contact with infected surfaces, wounds, and skin. Contact precautions — including gloves and gown worn upon entry to the room — are required. Airborne and droplet precautions are used for respiratory pathogens.
Question 2: A nurse discovers a fire in a client's room. Using the RACE protocol, which action should be taken first?
- Activate the fire alarm by pulling the nearest alarm
- Confine the fire by closing all doors and windows
- Rescue clients in immediate danger by moving them away from the fire (Correct answer)
- Extinguish the fire if it is small using the nearest fire extinguisher
Correct answer: Rescue clients in immediate danger by moving them away from the fire
The RACE acronym stands for Rescue, Alarm, Confine, Extinguish. Rescue (moving clients in immediate danger) is always the first priority. After all persons are safe, the alarm is activated, the fire is confined by closing doors, and extinguishment is attempted only if the fire is small and the exit is clear.
Question 3: A nurse is administering medications using the rights of medication administration. A client's medication administration record lists 'metoprolol 50 mg PO daily.' The pill available is labeled 'metoprolol succinate 100 mg.' The nurse should:
- Administer the 100 mg tablet and document that a double dose was given
- Split the 100 mg tablet in half and administer 50 mg as prescribed
- Clarify the order with the pharmacist before administering, as the tablet may be extended-release (Correct answer)
- Hold the medication and wait for the correct tablet to be dispensed
Correct answer: Clarify the order with the pharmacist before administering, as the tablet may be extended-release
Metoprolol succinate is an extended-release formulation that must never be split, crushed, or chewed, as this releases the entire dose at once. The nurse must clarify with pharmacy whether a non-scored tablet can be halved and confirm the correct formulation was dispensed before proceeding.
Question 4: A nurse is caring for a client who is confused and has been attempting to get out of bed unassisted. The call light is within reach and a bed alarm is in place. The family asks why the nurse is not using a restraint. The nurse explains that physical restraints:
- Are appropriate whenever a client is confused and a fall risk
- Can increase agitation, cause injury, and worsen confusion without improving safety (Correct answer)
- Require only the charge nurse's approval and can be applied at the bedside nurse's judgment
- Are the standard of care for all clients classified as high fall risk
Correct answer: Can increase agitation, cause injury, and worsen confusion without improving safety
Evidence shows that physical restraints do not prevent falls and can cause significant harm, including skin breakdown, aspiration, worsened agitation, and psychological trauma. They are a last resort after all alternatives have been tried. The Joint Commission discourages their use as a routine fall prevention measure.
Question 5: A nurse is preparing to administer a high-alert medication. Which safety strategy is most important before administration?
- Administer the medication quickly to avoid disruption during the process
- Rely on the electronic medication administration record to confirm the five rights
- Perform an independent double-check with a second nurse to verify drug, dose, route, and rate (Correct answer)
- Verify the medication name with the client before administration
Correct answer: Perform an independent double-check with a second nurse to verify drug, dose, route, and rate
High-alert medications (such as insulin, heparin, concentrated electrolytes, and chemotherapy) have a high risk of causing significant patient harm if used in error. An independent double-check by a second nurse is a mandatory safety process to verify all critical parameters before administration.
Question 6: A nurse is caring for a client who does not speak English. The client needs to provide informed consent for surgery. Which action by the nurse best protects the client's rights?
- Ask the client's bilingual family member to translate the consent information
- Arrange for a qualified medical interpreter to be present for the consent discussion (Correct answer)
- Have the client sign the consent form and document that a translator was unavailable
- Use a simplified version of the consent form written at a 3rd-grade reading level
Correct answer: Arrange for a qualified medical interpreter to be present for the consent discussion
Federal law and professional standards require the use of a qualified medical interpreter (in-person or via phone/video service) for informed consent discussions with clients who have limited English proficiency. Using family members as interpreters is inappropriate, as they may omit, alter, or misinterpret information.
Safe and Effective Care Environment 1
A nurse is receiving a client from the emergency department who has a history of MRSA.
Which transmission-based precaution is required?