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 demon
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Fundamentals of Nursing HESI

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?

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. A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client’s continuity of care?

Correct answer: D

Rationale: Starting discharge planning on the day of admission is crucial to ensuring a smooth transition and continuity of care for the client. It allows for early identification of needs, coordination of services, and timely interventions. Assigning a different nurse each shift (Choice A) can disrupt continuity of care and lead to inconsistencies in the client's treatment. Limiting the number of interdisciplinary team members (Choice B) may hinder comprehensive care coordination. Requesting a satisfaction survey at discharge (Choice C) focuses more on feedback rather than proactive care planning and coordination.

3. A nurse is providing teaching to an older adult client about home safety. Which of the following information should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'Keep a nightlight on in the bathroom.' This safety measure is crucial for older adults to prevent falls by enhancing visibility during nighttime bathroom visits. Choice B is incorrect because setting the room temperature to 68 degrees Fahrenheit may not be universally suitable for all older adults, as individual preferences vary. Choice C is incorrect as placing throw rugs over electrical cords poses a tripping hazard rather than enhancing safety. Choice D is incorrect as using chairs without armrests may not provide adequate support and stability for older adults, increasing the risk of falls.

4. A healthcare professional is using the I-SBAR communication tool to provide the client's provider with information about the client. The healthcare professional should convey the client's pain status in which portion of the report?

Correct answer: A

Rationale: In the I-SBAR communication tool, the 'Assessment' portion is where the healthcare professional should convey the client's pain status. This section includes the current patient information, such as the client's pain level, to provide a comprehensive view of the client's condition. Choice B ('Situation') typically involves a brief summary of the client's problem or reason for the communication. Choice C ('Background') usually covers the client's medical history and background information. Choice D ('Recommendation') focuses on the healthcare professional's suggestions or requests regarding the client's care plan, which may include pain management strategies but not the current pain status.

5. A 3-year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?

Correct answer: D

Rationale: The correct answer is D, Pinworms. Pinworms are a common cause of itching around the anal area, especially at night, in young children. Scratching the bottom and bedwetting can be indicative of a pinworm infection. Allergies (Choice A) are less likely given the symptoms described. Scabies (Choice B) may cause itching but is less common in causing bedwetting. Regression (Choice C) is not a common cause of these specific symptoms in a 3-year-old child.

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