Nursing Elites

1. During a sterile procedure at a client's bedside, a healthcare provider contaminates a sterile glove and the sterile field. What is the best action for the nurse to implement?

• A. Report the incident to the supervisor for aseptic technique violation.
• B. Allow the completion of the procedure.
• C. Inquire about the contamination of the glove and sterile field.
• D. Identify the breach in surgical asepsis and provide a new set of sterile supplies.

Correct answer: D

Rationale: In the scenario where a healthcare provider contaminates a sterile glove and the sterile field during a procedure, it is crucial to identify any breach in surgical asepsis. Any potential contamination should be considered compromised, and the nurse must act promptly to maintain sterility by providing a fresh set of sterile supplies for the procedure to continue safely.

2. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

• A. Loosen the right wrist restraint.
• B. Apply a pulse oximeter to the right hand.
• C. Compare hand color bilaterally.
• D. Palpate the right radial pulse.

Correct answer: A

Rationale: The priority nursing action is to restore circulation by loosening the restraint (A) because blue fingers (cyanosis) indicate decreased circulation. Comparing hand color bilaterally (C) and palpating the right radial pulse (D) are important assessments to gather more information, but they do not have the priority of addressing the decreased circulation by loosening the restraint. Applying a pulse oximeter (B) is not indicated in this scenario as it measures the saturation of hemoglobin with oxygen, which is not relevant when cyanosis is related to mechanical compression from the restraints.

3. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?

• A. Acknowledge that she is supporting the arm correctly.
• B. Encourage her to keep the joint uncovered to maintain warmth.
• C. Reinforce the need to grip directly under the joint for better support.
• D. Instruct her to grip directly over the joint for better motion.

Correct answer: A

Rationale: The wife is correctly performing the passive range-of-motion exercises by holding the arm above and below the elbow. The nurse should acknowledge this correct technique (A). It is essential to keep the joint uncovered (B) during exercises, while ensuring the rest of the body remains covered for warmth and privacy. Choices (C) and (D) do not provide optimal support to the joint for effective movement.

4. What is the main purpose of the working phase of the nurse-patient relationship?

• A. Establish a formal or informal contract that addresses the patient's problems.
• B. Implement nursing interventions that are designed to achieve expected patient outcomes.
• C. Develop rapport and trust so the patient feels supported, and the initial plan can be identified.
• D. Clearly identify the role of the nurse and establish the parameters of the professional relationship.

Correct answer: B

Rationale: The main purpose of the working phase in the nurse-patient relationship is to implement nursing interventions that are specifically tailored to achieve the expected patient outcomes. During this phase, the nurse actively works with the patient to put the care plan into action and make progress towards reaching the desired health goals. It involves the application of therapeutic communication, problem-solving, and interventions to address the patient's needs. Establishing rapport and trust is typically done in the orientation phase, while defining roles and boundaries usually occurs in the introductory phase of the relationship. Choices A, C, and D are incorrect as they describe activities more aligned with other phases of the nurse-patient relationship, such as orientation and introductory phases.

5. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?

• A. 13 ml/hour.
• B. 63 ml/hour.
• C. 80 ml/hour.
• D. 125 ml/hour.

Correct answer: B

Rationale: The correct calculation involves dividing the total volume by the total time. In this case, 250 ml/4 hours = 63 ml/hour. The dose of KCl is not used in the calculation as the focus is on the rate of infusion over the specified time period. Choice A (13 ml/hour) is incorrect as it does not result from the correct calculation. Choice C (80 ml/hour) and Choice D (125 ml/hour) are also incorrect calculations and do not match the correct rate of infusion required.

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