RNSG 1105-Mastery Checkoff Latest Updated 2024/2025 with Complete Solutions Entry Measures - Correct Answer I. Verify Health Care Provider's (HCP's) orders and/or hospital policy.II. Gather all needed equipment and supplies. Check expiration dates as needed.
Entry Measures:
- Perform hand hygiene, put on PPE, if indicated.
- Provide privacy - close door or close curtain
- Greet patient and introduce self (Name, ACC Nursing Student)
- Identify patient using two acceptable identifiers (ask patient their name & assess MR#)
- Ask patient if they have any allergies.
- Explain the procedure to the patient and why this intervention is needed. Answer any questions as
- Raise bed to a working height and put down side rail.
- 4 P's (Pain, Potty, Possessions and Position).
- Bed in lowest position.
- Two side rails up.
- Call bell within reach.
- Perform hand hygiene as exit room.
- Stand in front of sink without hands or clothing touching the sink during washing.
- Turn on water, adjust water force (avoid splashing water against uniform), and regulate
needed.
Exit Measures - Correct Answer 1. Verbalize to patient that you are leaving.
Hand Hygiene using Soap and Water: Equipment Needed - Correct Answer Antimicrobial soap, paper towels, running water.Hand Hygiene using Soap and Water - Correct Answer 1. Push watch and sleeves above wrists, remove any rings.
temperature until water warm. Wet the hands and wrist area keep hands lower than elbows; allow flow water to drain downward toward the fingertips. 1 / 4
- Apply soap using about 3-5 mL of liquid antiseptic soap from dispenser. Lather your hands by
- Wash hands using mechanical friction and circular motions to lather the soap going from clean to
- Wrist
- Back of hands / Palms/ Fingers
- In between fingers- web areas
- Fingertips and Nails
- Rinse hands under clean running water so that the soap drains from the forearm to the fingertips
- Using a fresh dry paper towel, pat hands dry wiping from forearms to wrists to fingers. Dry hands
- Dispose wet paper towels into proper waste container.
- Use another dry paper towel to turn off the faucet. Dispose in proper waste container.
- Dispense ample amount of product to palm of one hand, using about 1-3 mL.
- Rub hands together, making sure to cover all surfaces of the palms, back of hands, thumb and
- Continue rubbing hands for several seconds until alcohol is completely dry. ( at least 15 seconds)
- Gown: Put on gown, with opening in the back taking care to cover the entire front and back of 2 / 4
rubbing together with the soap being sure to cover all areas of hands with soap product.
dirty, for at least 15 seconds.
(clean to dirty).
thoroughly. (May use another dry paper towel if needed to ensure hands get dry).
Hand Hygiene Using Alcohol-Based Hand rub: Equipment Needed - Correct Answer Alcohol-based Hand rub Hand Hygiene Using Alcohol-Based Hand rub - Correct Answer 1. Push watch and sleeves above wrists, remove any rings.
wrists, fingers, and fingertips.
When is handwashing with alcohol-based hand rub used? - Correct Answer Mainly when entering a patient's room and anytime that hands have not been working with contaminated items.Personal Protective Equipment (PPE): Prechecks and putting on PPE - Correct Answer I. Verify HCP orders to determine which PPE are to be used.II. Equipment Needed: Gloves, masks, impervious gown, protective eyewear (when appropriate).Putting on PPE
uniform. Tie gown securely at back of gown (tie neck first and then waist).
- Mask: Put on mask, with blue facing outward and wire on top. Secure it over the nose, mouth and
chin. If mask has ties - tie head first then at neck. If elastic, pull around ears. Press wire around nose.
3. Goggles: Put on goggles or face shield when appropriate.
- Gloves: Pull cuffs of gown down over part of hands prior to applying gloves. Apply gloves, making
- Free your Wrists - Grasp gown near cuff area and pull up exposing about an inch of skin, do this on
- Glove to glove - Pinch palm area (stay away from cuff), with opposite gloved hand and pulls off
- Finger to skin - Slide clean finger of ungloved hand under cuff of dirty glove and remove turning
- Dispose in proper waste container.
sure extending gloves to cover the cuff of the gown sleeve. No exposed skin!Personal Protective Equipment (PPE): Removing PPE - Correct Answer 1. Remove gloves:
both sides.
glove turning glove inside out holding dirty glove in palm of gloved hand. (dirty to dirty)
inside out, taking care not to touch the outer surface. (clean to clean)
2. Remove goggles/face shield (only if appropriate):
- Grasp goggles/face shield by head band or earpieces
- Lift away from face
- Dispose in proper waste container.
3. Remove gown:
- Unfasten ties of waist and then tie at neck. Pull gown off shoulders by just holding ties and then let
- Slide clean finger under gown cuff, pull gown down over hand making a mitt. (clean to clean)
- With mitt hand, grasps opposite gown sleeve and pull gown down, (dirty to dirty) allowing gown to
- Keeping hands on inner surface of gown pull from arms and remove gown without touching
- Turn gown inside out
- Fold or roll gown into a bundle, stopping about 12 inches before the bottom edge and discard in
go.
fall away from shoulder, making a mitt.
outside surface.
proper waste container.
4. Remove mask: 3 / 4
- For elastic - grasp elastic loops and pull off, being careful to touch only the elastic.
- For tie mask - Grasp the neck ties first and then the head ties and remove. Take care to avoid
- Discard in proper waste container.
- Perform hand hygiene immediately after removing PPE.
- Determine need for restraints. Assess patient's physical condition, behavior, and mental status.
- Make sure that all alternatives have been tried prior to use of restraints and determine failure of
- Confirm agency policy for application of restraints. Secure a health care provider's order or
- Explain reason for use to patient and family. Explain that it is a temporary measure. Determine if a
- Inspect area where restraint is to be placed. (nearby equipment, tubing, condition of patients skin)
touching front of mask.
When do you remove the PPE? What is the exception? - Correct Answer Remove all PPE BEFORE exiting the patients room.ONLY exception is N95 mask in an airborne precaution: Remove mask after leaving patient room, closing the door, and AFTER entering anteroom Applying an Extremity Restraint: Equipment Needed - Correct Answer Cloth restraint, padding for bony prominences if necessary Applying an Extremity Restraint: Prior to Application - Correct Answer Prior to Application:
(e.g., confusion, disorientation, agitation, repeated removing of tubing or dressings)
the alternative measures.
validate that the order has been obtained within the past 4 hours.
signed consent for use of restraint is necessary.Applying an Extremity Restraint: Implementation - Correct Answer 1. Be sure patient is in a comfortable position and in proper body alignment.
3. Apply restraint according to manufacturer's directions:
- Choose the least restrictive type of device that allows the greatest possible degree of mobility.
- Pad bony prominences if needed.
- Wrap the restraint around the extremity with the soft part in contact with the skin.
- Secure restraint with the Velcro® straps or quick release buckle or knot at the extremity, ensuring
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that it does not tighten around the extremity upon movement.