Nursing Elites

1. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?

• A. Use sterile gloves only as necessary
• B. Restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray
• C. Keep the dressing tray on a nearby surface
• D. Avoid speaking during the procedure

Correct answer: B

Rationale: The correct action to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray. Any contact with the sterile field by non-sterile items makes the field contaminated and requires restarting the procedure to maintain sterility. Choice A is incorrect because sterile gloves should always be used during a sterile procedure to prevent contamination. Choice C is incorrect as the dressing tray should be placed on a sterile surface, not on the client's bed, to maintain sterility. Choice D is also incorrect as talking during the procedure does not necessarily lead to contamination if proper aseptic technique is maintained.

2. A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?

• A. Postpartum depression
• B. Taking-in phase
• C. Postpartum blues
• D. Taking-hold phase

Correct answer: C

Rationale: The client is experiencing postpartum blues, not postpartum depression. Postpartum blues are common and characterized by mood swings, tearfulness, and emotional letdown shortly after delivery. The 'Taking-in phase' involves the mother focusing on her own needs, while the 'Taking-hold phase' is characterized by a desire to learn and feel competent in caring for the baby. Postpartum depression is a more severe and long-lasting condition that requires professional intervention.

3. A client is receiving morphine. Which of the following should the nurse monitor?

• A. Liver function
• B. Respiratory rate
• C. Blood glucose levels
• D. Bowel sounds

Correct answer: B

Rationale: Corrected Rationale: When a client is receiving morphine, monitoring the respiratory rate is crucial because morphine can cause respiratory depression. Therefore, it is essential for the nurse to assess the client's breathing to detect any signs of respiratory distress. Choices A, C, and D are incorrect because morphine primarily affects the respiratory system, not the liver function, blood glucose levels, or bowel sounds.

4. A nurse is providing discharge teaching to a client who has a prescription for home oxygen. Which information should the nurse teach?

• A. Use a humidifier with the oxygen
• B. Wear cotton socks when the oxygen is in use
• C. Avoid all types of smoking materials
• D. Use a nasal cannula during meals

Correct answer: B

Rationale: The correct answer is B: 'Wear cotton socks when the oxygen is in use.' This information is important as wearing cotton socks helps prevent static electricity, which can pose a fire risk when oxygen is in use. Choice A is incorrect as using a humidifier with oxygen is not necessary for all clients and may not be part of standard discharge teaching. Choice C is incorrect as it is a common safety measure to avoid all types of smoking materials when using oxygen. Choice D is incorrect as using a nasal cannula during meals is not specifically related to the safety concerns associated with home oxygen use.

5. While receiving a change of shift report on a group of clients, which patient should the nurse assess first?

• A. The client who has a fractured femur and reports sharp chest pain.
• B. The client who has a fever and is receiving antibiotics.
• C. The client who has a urinary tract infection and reports pain with urination.
• D. The client who is scheduled for surgery in the afternoon.

Correct answer: A

Rationale: The nurse should assess the client with a fractured femur and sharp chest pain first. Sharp chest pain in this client may indicate a pulmonary embolism, a life-threatening condition requiring immediate attention. The other options describe important patient conditions but do not pose an immediate threat to life like a potential pulmonary embolism does.

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