a charge nurse is observing a newly licensed nurse prepare a sterile fielwhich of the following actions should the charge nurse identify as contaminat
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Nursing Elites

HESI LPN

Fundamentals HESI

1. A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

Correct answer: A

Rationale: The correct answer is A. Opening the sterile field on a wet surface contaminates it, rendering it unsafe for use. Moisture can carry microorganisms that can compromise the sterility of the field. Choice B is incorrect because turning away from the sterile field alone does not necessarily contaminate it unless the nurse touches non-sterile items. Choice C is incorrect because using a non-sterile glove to touch the sterile field directly introduces contaminants. Choice D is incorrect as touching the edge of the sterile drape with a hand may not necessarily contaminate the entire field, unlike opening it on a wet surface.

2. A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?

Correct answer: A

Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.

3. What is the most important action for the LPN/LVN to take to prevent infection in a client with an indwelling urinary catheter?

Correct answer: A

Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This step helps prevent obstruction in the tubing, maintaining proper urine flow and reducing the risk of infection. Changing the catheter every 72 hours is not recommended unless clinically indicated, as routine changes can increase the risk of introducing pathogens. Cleaning the perineal area with an antiseptic solution is essential for general hygiene but does not directly prevent catheter-related infections. Irrigating the catheter with normal saline every shift is not a standard practice and can introduce microorganisms into the urinary tract, increasing the risk of infection.

4. The healthcare provider is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the healthcare provider use when reporting to the oncoming shift?

Correct answer: B

Rationale: The correct term the healthcare provider will use when reporting the extremely bad breath of the unconscious patient to the oncoming shift is 'Halitosis' (Choice B). Halitosis specifically refers to bad breath. Cheilitis (Choice A) is inflammation of the lips, not related to bad breath. Glossitis (Choice C) is inflammation of the tongue, not directly associated with bad breath. Dental caries (Choice D) are cavities in the teeth, which can contribute to bad breath but are not the term used to describe bad breath itself.

5. A young adult client is receiving instruction from a healthcare provider about health promotion and illness prevention. Which of the following statements indicates understanding?

Correct answer: B

Rationale: The correct answer is B. Scheduling routine health care visits, even when feeling well, is crucial for early detection and prevention of health issues. This proactive approach allows healthcare providers to monitor overall health, provide preventive care, and address any emerging health concerns promptly. Choice A is incorrect because past immunizations do not cover all potential diseases; regular check-ups are still necessary. Choice C is incorrect as urgent care centers are not designed for routine medical care. Choice D is incorrect as seeking help for stress is important for mental well-being and should not be dismissed as a normal part of life.

Similar Questions

When orienting a newly licensed nurse on taking a telephone prescription, which statement indicates understanding of the process?
The nurse is admitting a patient diagnosed with a stroke. The healthcare provider writes orders for 'ROM as needed.' What should the nurse do next?
A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication is not an option for managing pain. Which of the following is an appropriate response by the nurse?
A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?
A healthcare professional is calculating a client's fluid intake over the past 8 hr. Which of the following should the healthcare professional plan to document on the client's intake and output record as 120 mL of fluid?

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