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Alternate format test 4 (SATA) Questions & answers
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Alternate format test 4 (SATA)The nurse notes that a patient is positive for the hepatitis B surface antigen. Which
questions should the nurse include in the patient's assessment to help determine the
source of the infection?
Select all that apply.
1. "Have you been anywhere where the water may have been contaminated?"
2. "Have you eaten any food in areas where the workers may not have had access to
hand washing?"
3. "Have you had unprotected sex with anyone who has hepatitis B?"
4. "Have you eaten any raw shellfish lately?"
5. "Have you had a recent blood transfusion?"
6. "Do you share needles with anyone?" - ANS-Show/hide explanation
1) hepatitis A is spread through the fecal-oral route by ingestion of fecal contaminants
2) hepatitis A is spread through the fecal-oral route by ingestion of fecal contaminants
3) CORRECT - hepatitis B is shed in the body fluid of infected individuals; a mode of
transmission of hepatitis B is from unprotected sex with someone who is infected
4) refers to transmission hepatitis A
5) CORRECT - hepatitis B is shed in the body fluid of infected individuals; a mode of
transmission of hepatitis B is from blood transfusions
6) CORRECT - hepatitis B is shed in the body fluid of infected individuals; a mode of
transmission of hepatitis B is needle sharing
The nurse provides care for a newly delivered infant with a temperature of 97.2 °F
(36.2°C). Which actions will the nurse take when caring for this newborn?
Select all that apply.
1. Place the newborn skin-to-skin on the mother's chest.
2. Double wrap the newborn in blankets from the clean linen cart.
3. Place a hat/cap on the newborn's head.
, 4. Place the dry and diapered newborn under a radiant warmer.
5. Bathe the newborn in warm water while protecting the umbilical stump. -
ANS-Show/hide explanation
1) CORRECT- Infant needs to be warmed. Skin-to-skin maternal-infant contact can help
raise the infant's temperature.
2) Cover the couplet with a warmed blanket. Blankets for newborns with a low
temperature need to be pre-warmed; blankets from the linen cart are not pre-warmed.
3) CORRECT - Covering the newborn's head with a hat/cap, or swaddling in a blanket
with its head covered, will help prevent heat loss from the head.
4) CORRECT - Newborns need to wear only a diaper under a radiant warmer; this
action increases the surface area to absorb the radiant heat.
5) Newborns need to be thermodynamically stable prior to the first bath. The newborn
will lose heat due to evaporation during the bath.
The client was recently admitted from the emergency department. The nurse prepares
the client's prescribed medications. Which steps 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-Show/hide explanation
1) double verification is only required for specific medications, such as insulin;
double-verifying all medications is impractical; some calculated dosages should be
double-checked
2) documentation of medication administration is completed immediately after the
delivery, not before
,3) use at least two client identifiers when administering medications
4) CORRECT — prepare medications for only one client at a time in an uninterrupted
environment
5) CORRECT — medication needs to be verified if the dose seems too large or too
small
6) CORRECT — labels need to be read at least 3 times and verified with the medication
record
The nurse administers medication. While documenting the administration, the nurse
realizes an error in administration. Which actions must the nurse take?
Select all that apply.
1. Evaluate the effect of the medication.
2. Notify the patient's health care provider.
3. Call the hospital's Risk Manager.
4. Notify the patient of the error.
5. Notify the nurse's attorney.
6. Complete an occurrence report. - ANS-Show/hide explanation
1) CORRECT - One of the nurse's role is evaluation of therapeutic modalities, even if
the patient receives an incorrect treatment.
2) CORRECT - The nurse needs to notify the health care provider, the patient, and the
charge nurse/nurse manager all need to be informed of the error.
3) Risk Management will be informed via the occurrence/incident report. The
department does not need to be informed separately. If the error is significant, e.g.
resulted in a death, then the nurse manager will need to contact the Risk Manager.
4) CORRECT - Appropriate action.
5) An attorney needs to be involved only if the patient is harmed. There is no
information indicating harm, and harm is not automatically assumed in the event of an
erroneous medication administration.
6) CORRECT - The nurse needs to complete an occurrence/incident report .
, The nurse prepares a dose of enoxaparin (Lovenox) for the patient after a hip
replacement. Which supplies will the nurse need to best deliver the prescribed
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-Show/hide explanation
1) Lovenox is only administered subcutaneously (SQ). A routine dose of Lovenox is less
than 1 mL and is most safely administered from a 1 mL syringe.
2) CORRECT - A smaller gauge needle is appropriate because the medication is
delivered subcutaneously.
3) A medication cup is not necessary because the medication is delivered SQ.
4) CORRECT - Alcohol swabs are needed to prepare the skin prior to administration.
5) CORRECT - For safety reasons, the medication must be labeled after it is drawn.
An 88-year-old client has two units of packed blood cells ordered for transfusion. The
client does not have an IV. Which supplies 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-Show/hide explanation
1) when administering blood, the secondary solution is normal saline, which reduces the
risk of hemolysis of the red cells
2) CORRECT — blood is administered with a 20-micron in-line filter
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