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. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?

• A. Determine the client's sleep and activity pattern
• B. Obtain a prescription for the client to take when stressed
• C. Refer the client for a sleep study and neurological follow-up
• D. Teach coping strategies to use when feeling stressed

Correct answer: A

Rationale: The correct intervention for the nurse to implement in this scenario is to determine the client's sleep and activity pattern. By assessing the client's patterns, the nurse can identify factors contributing to the sleep issues and tailor appropriate interventions. Choice B is incorrect because prescribing medication without a comprehensive assessment is not the initial step. Choice C is unnecessary at this stage as the client's symptoms are likely related to stress rather than a neurological disorder. Choice D, while important, should come after understanding the client's sleep patterns to provide holistic care. Therefore, option A is the best choice to address the client's sleep difficulties and headaches effectively.

3. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes, the client was told by the family member to turn to the right side. What is the appropriate comment for the nurse to make?

• A. Why don’t we now have the client turn back to the left side?
• B. That was done correctly. Did you have any problems with the insertion?
• C. Let’s check to see if the suppository is in far enough.
• D. Did you feel any stool in the intestinal tract?

Correct answer: B

Rationale: Choice B is the correct answer because the family member's actions in administering the rectal suppository were correct. Providing positive feedback and asking if there were any problems with the insertion is an appropriate response. Choice A is incorrect because there is no need to have the client turn back to the left side after the suppository has been administered. Choice C is incorrect as there is no indication that the suppository was not inserted correctly, so there is no need to check if it is in far enough. Choice D is incorrect because feeling stool in the intestinal tract is not relevant to the administration of a rectal suppository.

4. A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?

• A. Decrease in heart rate
• B. Fluid volume deficit causes tachycardia
• C. Decrease in blood pressure
• D. Increase in respiratory rate

Correct answer: A

Rationale: A decrease in heart rate can indicate that the fluid volume deficit is improving. In cases of fluid volume deficit, the body compensates by increasing the heart rate to maintain adequate perfusion. Therefore, a decrease in heart rate after fluid resuscitation suggests that the body's perfusion status is improving. Choices B, C, and D are incorrect because fluid volume deficit typically causes tachycardia, not a decrease in heart rate, and would not result in a decrease in blood pressure or an increase in respiratory rate as primary signs of improvement.

5. What action should the LPN/LVN take to prevent postoperative complications in a client who has undergone abdominal surgery?

• A. Encourage the client to use an incentive spirometer regularly.
• B. Assist the client in ambulating as soon as possible.
• C. Position the client in high Fowler's position.
• D. Encourage the client to cough and deep breathe regularly.

Correct answer: A

Rationale: Encouraging the client to use an incentive spirometer regularly is crucial in preventing postoperative complications after abdominal surgery. This action helps prevent atelectasis by promoting lung expansion and improving air exchange in the lungs, reducing the risk of respiratory complications. Assisting the client in ambulating early is important for preventing issues like deep vein thrombosis but may not directly address respiratory concerns postoperatively. Positioning the client in high Fowler's position can help with respiratory distress but is not as specific to preventing postoperative respiratory complications as using an incentive spirometer. While encouraging the client to cough and deep breathe is generally beneficial for lung expansion, using an incentive spirometer is more effective and targeted in preventing atelectasis after abdominal surgery.

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