Alternate format test 4 (SATA) questions and
correct answers With Rationale. With Complete
Solution.
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?"
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.
,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.
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.
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.
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.
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