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Alternate format test Questions & answers
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Alternate format testA newly delivered client has a temperature of 97.2°F (36.2°C). Which action does the
nurse take when caring for this newborn? (Select all that apply.)
1. Places the newborn skin-to-skin on the parent's chest.
2. Double wraps the newborn in blankets from the clean linen cart.
3. Places a hat/cap on the newborn's head.
4. Places the dry and diapered newborn under a radiant warmer.
5. Bathes the newborn in warm water while protecting the umbilical stump. - ANS-1.
Places the newborn skin-to-skin on the parent's chest.
3. Places a hat/cap on the newborn's head.
4. Places the dry and diapered newborn under a radiant warmer.
NOT
2. Double wraps the newborn in blankets from the clean linen cart.
-Blankets taken from the linen cart are cold and won't help to warm the newborn. If a
blanket is to be used, it can be used to cover the newborn as it is skin-to-skin with a
parent. Also, if a blanket is to be used for a newborn with a low T, it needs to be
prewarmed
5. Bathes the newborn in warm water while protecting the umbilical stump.
The nurse prepares an adult client's prescribed medications. Which step does the nurse
take to ensure the client receives the correct medication? (Select all that apply.)
1. Asks another nurse to verify the medications after retrieving the medications from the
medication system.
2. Documents the administration of the medications before delivering them to the client.
3. Calls the client by name only to make sure the correct client is receiving the correct
medication.
4. Focuses only on the delivery of the medication for the client.
5. Questions the prescriber of a medication if the dose seems too large.
6. Verifies the medication label with the medication administration record three times. -
ANS-4. Focuses only on the delivery of the medication for the client.
5. Questions the prescriber of a medication if the dose seems too large.
6. Verifies the medication label with the medication administration record three times.
#4 meant to prepare medications for only ONE client at a time
,NOT
1. Asks another nurse to verify the medications after retrieving the medications from the
medication system.
-Double verification is only required for some specific meds, e.g. insulin. This answer
did not specify for insulin/specific meds, so DO NOT ASSUME anything the
question/answer does not explicitly say. Double verification of all meds is impractical
2. Documents the administration of the medications before delivering them to the client.
3. Calls the client by name only to make sure the correct client is receiving the correct
medication.
The nurse administers medication. While documenting the administration, the nurse
realizes an error in administration has been made. Which action must the nurse take?
(Select all that apply.)
1. Evaluate the effect of the medication.
2. Notify the client's health care provider.
3. Call the hospital's Risk Manager.
4. Notify the client of the error.
5. Notify the nurse's attorney.
6. Complete an occurrence report. - ANS-1. Evaluate the effect of the med
2. Notify the HCP
4. Notify the client of the error
6. Complete an occurrence report
The nurse needs to notify the HCP, the client, and the charge nurse/nurse manager.
No need to call the risk manager/management department. They will be informed by the
occurrence/incident report. If the error is huge, e.g. a pt died, then the nurse manager
will need to contact the Risk Manager.
An attorney only needs to be involved if the client is harmed.
The nurse prepares a dose of enoxaparin for an adult client after a hip replacement.
Which item does the nurse need to best deliver the medication from a multi-dose vial?
(Select all that apply.)
1. A 3 mL syringe.
2. A 28 gauge needle.
3. A medication cup.
, 4. Alcohol swabs.
5. A medication label. - ANS-2. A 28 gauge needle
4. Alcohol swabs
5. A medication label
Enoxaparin is an anticoagulant and administered ONLY SQ. A routine dose is <1 mL
and is most safely administered from a 1 mL syringe
A small gauge needle is appropriate because the med is delivered SQ
An older adult client is prescribed two units of packed red blood cells transfused. The
client does not have an IV. Which supply item does the nurse gather when preparing to
administer the blood? (Select all that apply.)
1. Secondary solution of 5% dextrose solution.
2. Filtered piggyback tubing.
3. 20 gauge IV cannula.
4. Blood pressure cuff.
5. Thermometer.
6. Glucometer. - ANS-2. Filtered piggyback tubing.
3. 20 gauge IV cannula.
4. Blood pressure cuff.
5. Thermometer.
"Filtered piggyback tubing" refers to the blood administration set which has a filter. "
Normal cannula size for blood admin is 18-20G
Is comparing the client to a photo is an appropriate identifier before med admin etc? -
ANS-YES
An adult client is scheduled to have a left cataract removal and lens replacement. The
nurse verifies the consent with the client. The nurse marks the client's left eye. Just
before surgery, the nurse calls for a "time-out." Which action is included in the
"time-out?" (Select all that apply.)
1. The health care provider indicates the left eye is the operative eye.
2. The anesthesiologist verifies the consent has been signed.
3. The scrub nurse uses instruments indicated only for the left eye.
4. The client indicates removal of the left eye cataract.
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