Nursing Elites

1. A scrub nurse preparing for the first surgery of the day asks if a 3-minute surgical hand scrub is adequate. What should the circulating nurse advise?

• A. Proceed with surgery preparation
• B. Extend scrub time to 5 minutes
• C. Use an alcohol-based hand sanitizer
• D. Scrub time depends on the type of surgery

Correct answer: B

Rationale: The circulating nurse should advise the scrub nurse to extend the hand scrub to 5 minutes for thorough preparation, especially for the first surgery of the day. Choice A is incorrect as it does not address the need for a longer scrub time. Choice C is incorrect as alcohol-based hand sanitizer is not a substitute for a thorough surgical hand scrub. Choice D is incorrect as while scrub time may vary based on the surgery, for the first surgery of the day, a longer scrub time is recommended as a standard practice.

2. The nurse is caring for a client with an indwelling urinary catheter. Which of the following actions should the nurse prioritize to prevent infection?

• A. Maintain a closed drainage system
• B. Cleanse the catheter insertion site daily
• C. Increase the client's fluid intake
• D. Empty the collection bag every 4 hours

Correct answer: A

Rationale: The correct answer is to maintain a closed drainage system. This action is crucial in preventing infection as it helps prevent bacteria from entering the urinary tract. While cleansing the catheter insertion site and ensuring adequate hydration are important aspects of catheter care, the top priority is maintaining the integrity of the closed system to prevent infection. Emptying the collection bag regularly is also important but not as critical as ensuring a closed drainage system to minimize infection risk.

3. A client is experiencing chest pain and is prescribed nitroglycerin. What should the nurse assess before administering the medication?

• A. Monitor the client’s oxygen saturation level.
• B. Check the client’s heart rate and blood pressure.
• C. Evaluate the client’s level of consciousness.
• D. Assess the client's chest pain severity using a pain scale.

Correct answer: B

Rationale: Before administering nitroglycerin, it is crucial to check the client’s heart rate and blood pressure. Nitroglycerin can lower blood pressure and heart rate, so assessing these parameters is essential to prevent exacerbating hypotension or bradycardia. While monitoring the client’s oxygen saturation level is important in some situations, it is not the primary assessment needed before administering nitroglycerin. Evaluating the client’s level of consciousness is relevant for other conditions but not specifically necessary before giving nitroglycerin. Assessing chest pain severity using a pain scale is valuable for pain management but is not the priority assessment before administering nitroglycerin.

4. A client is admitted with a suspected pulmonary embolism (PE). What is the nurse's priority intervention?

• A. Administer anticoagulant therapy as prescribed.
• B. Elevate the head of the bed to 45 degrees.
• C. Check the client's oxygen saturation.
• D. Prepare the client for a CT scan.

Correct answer: D

Rationale: The correct answer is to prepare the client for a CT scan. A CT scan is essential in confirming the presence of a pulmonary embolism (PE) and guiding further treatment. Administering anticoagulant therapy (Choice A) is important in the management of PE, but it is not the priority intervention in this case. Elevating the head of the bed (Choice B) is beneficial for optimizing oxygenation but is not the priority intervention when a PE is suspected. Checking the client's oxygen saturation (Choice C) is important, but obtaining a definitive diagnosis through a CT scan takes precedence in this situation.

5. Which intervention should the nurse include in the care plan for a child with tetanus?

• A. Ensure proper hydration
• B. Administer prescribed antibiotics
• C. Monitor vital signs frequently
• D. Minimize the amount of stimuli in the room

Correct answer: D

Rationale: The correct intervention for a child with tetanus is to minimize the amount of stimuli in the room. Tetanus causes severe muscle spasms and sensitivity to stimuli, so reducing stimuli like light, sound, and touch can help prevent painful spasms. While ensuring proper hydration and administering antibiotics are essential components of care, minimizing stimuli is crucial for the child's comfort and safety as it directly addresses the symptoms associated with tetanus.

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