Nursing Elites

1. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing techniques?

• A. The nurse washes with her hands held higher than her elbows.
• B. The nurse uses a brush to scrub under her nails.
• C. The nurse washes for at least 30 seconds.
• D. The nurse uses alcohol-based hand rub only.

Correct answer: A

Rationale: Proper surgical hand-washing technique involves keeping the hands higher than the elbows to prevent contamination. Washing with hands held lower than the elbows can lead to potential contamination. Using a brush to scrub under the nails is not recommended as it can cause microabrasions, increasing infection risk. While washing for at least 30 seconds is a good practice for thorough hand hygiene, hand positioning is critical during surgical hand-washing. Using alcohol-based hand rub alone is insufficient for surgical hand-washing as it may not effectively remove dirt, debris, and transient microorganisms.

2. The healthcare professional is preparing to administer a tuberculin skin test. Which site is most appropriate for this injection?

• A. Deltoid muscle
• B. Vastus lateralis muscle
• C. Abdomen
• D. Inner forearm

Correct answer: D

Rationale: The inner forearm is the most appropriate site for administering a tuberculin skin test. This test requires an intradermal injection, which is administered just below the surface of the skin. The inner forearm provides a flat, easily accessible surface for this type of injection. Choices A, B, and C are incorrect because the tuberculin skin test should not be administered into a muscle (deltoid muscle or vastus lateralis muscle) or into the abdomen. The test requires precise placement within the dermal layer of the skin on the inner forearm to accurately assess for a reaction.

3. A healthcare provider is preparing to provide hygiene care. Which principle should the provider consider when planning hygiene care?

• A. Hygiene care is not performed in the same way by all individuals.
• B. No two individuals perform hygiene in the same manner.
• C. Standardizing a patient's hygienic practices is crucial.
• D. Understanding patient needs is not essential during hygiene care.

Correct answer: B

Rationale: The correct answer is B: 'No two individuals perform hygiene in the same manner.' It is crucial to individualize a patient's care based on understanding the patient's unique hygiene practices and preferences. Choice A is incorrect because hygiene care should be tailored to the individual's needs and preferences, not seen as routine and expected for everyone. Choice C is incorrect as standardizing a patient's hygienic practices may not address their specific needs. Choice D is incorrect because understanding patient needs is essential during hygiene care to provide personalized and effective care.

4. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicates a potential hazard for this test?

• A. Reflex incontinence
• B. Allergic to shellfish
• C. Claustrophobia
• D. Hypertension

Correct answer: B

Rationale: The correct answer is B, 'Allergic to shellfish.' An allergy to shellfish can indicate a sensitivity to iodine, which is used in the contrast dye for an IVP, posing a risk of an allergic reaction. Reflex incontinence (Choice A) is not directly related to the potential hazard of an IVP. Claustrophobia (Choice C) and hypertension (Choice D) are also not significant factors that indicate a potential hazard for an IVP.

5. 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 correct action to take first when observing blue fingers in a client with wrist restraints is to loosen the right wrist restraint. Blue fingers indicate compromised circulation, and loosening the restraint can help restore blood flow to the area. Applying a pulse oximeter (Choice B) or palpating the right radial pulse (Choice D) may be necessary following the loosening of the restraint to assess the client's oxygen saturation and pulse. Comparing hand color bilaterally (Choice C) is important but not the immediate action needed when a circulation issue is noted in one hand.

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