Nursing Elites

1. A nurse is preparing a sterile field for a client with a surgical wound. Which of the following actions should the nurse take to maintain the sterile field?

• A. Open sterile packages using the flap closest to your body first.
• B. Don sterile gloves before opening the sterile package.
• C. Avoid reaching over the sterile field.
• D. Place sterile items at least 2.5 cm (1 in) from the edge of the sterile field.

Correct answer: C

Rationale: The correct action to maintain a sterile field is to avoid reaching over it. This prevents contamination of the sterile environment by reducing the risk of unintentionally dropping microorganisms from non-sterile areas onto the sterile field. Opening sterile packages using the flap closest to your body first (choice A) is a good practice but not directly related to maintaining the sterile field. Donning sterile gloves before opening the sterile package (choice B) is crucial for maintaining sterility but not specific to maintaining the sterile field. Placing sterile items at least 2.5 cm (1 in) from the edge of the sterile field (choice D) is important to prevent accidental contamination, but it is not the primary action to maintain the sterile field.

2. What is the best position for a patient experiencing shortness of breath?

• A. Supine position
• B. Semi-Fowler's position
• C. Trendelenburg position
• D. Prone position

Correct answer: B

Rationale: The best position for a patient experiencing shortness of breath is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Supine position (lying flat on the back) may worsen breathing difficulties by reducing lung capacity. The Trendelenburg position (feet elevated higher than the head) is not recommended for patients with shortness of breath as it can increase pressure on the diaphragm and compromise breathing. The Prone position (lying face down) is also not suitable for patients experiencing shortness of breath as it may further restrict breathing.

3. A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

• A. Clamp the chest tube for 15 minutes every 2 hours.
• B. Empty the drainage collection chamber when it is half full.
• C. Keep the drainage system below the level of the client's chest.
• D. Strip the chest tube every 2 hours to maintain patency.

Correct answer: C

Rationale: The correct action the nurse should take when caring for a client with a chest tube is to keep the drainage system below the level of the client's chest. This positioning helps prevent fluid from flowing back into the pleural space, ensuring proper drainage and effective functioning of the chest tube. Clamping the chest tube intermittently or stripping it frequently can lead to complications and should be avoided. Emptying the drainage collection chamber at specific intervals may vary based on institutional protocols, but it should be done when it is no more than two-thirds full to prevent backflow and maintain accurate monitoring of drainage output.

4. How should a healthcare professional assess a patient's pain level post-surgery?

• A. Use a pain rating scale
• B. Check vital signs
• C. Observe for non-verbal cues
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: Corrected Rationale: Using a pain rating scale is the most appropriate method to assess a patient's pain level post-surgery. Pain rating scales provide a standardized way for patients to communicate their pain intensity, allowing for accurate assessment and effective pain management. Checking vital signs (choice B) is important for monitoring a patient's overall health status but may not directly reflect their pain level. Observing for non-verbal cues (choice C) is valuable, but it may not always provide a clear indication of the pain intensity. Checking for abnormal breath sounds (choice D) is relevant for assessing respiratory status but does not directly evaluate the patient's pain level.

5. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse identify as a manifestation of digoxin toxicity?

• A. Constipation.
• B. Tachycardia.
• C. Visual disturbances.
• D. Hypertension.

Correct answer: C

Rationale: Visual disturbances, such as blurred or yellow vision, are common signs of digoxin toxicity. While constipation (Choice A) is not typically associated with digoxin toxicity, tachycardia (Choice B) and hypertension (Choice D) are not characteristic manifestations of digoxin toxicity. Therefore, the correct answer is visual disturbances (Choice C).

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