Nursing Elites

1. All of the following statements are true about donning sterile gloves except:

• A. The first glove should be picked up by grasping the inside of the cuff.
• B. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove.
• C. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist.
• D. The inside of the glove is considered sterile.

Correct answer: D

Rationale: When donning sterile gloves, it is essential to maintain sterility. The correct way to don sterile gloves includes grasping the outside of the cuff to put on the first glove and inserting the gloved fingers under the cuff outside the glove to put on the second glove. Adjustments should be made by sliding the fingers under the sterile cuff. It is crucial to remember that once the inside of the glove is touched during the donning process, it is no longer considered sterile.

2. Which type of illness is characterized by severe symptoms of relatively short duration?

• A. Chronic Illness
• B. Acute Illness
• C. Pain
• D. Syndrome

Correct answer: B

Rationale: The correct answer is B: Acute Illness. Acute illnesses are characterized by the sudden onset of severe symptoms that typically last for a short duration. These conditions usually resolve within a defined period, unlike chronic illnesses that persist over a longer time frame. Choices C and D, Pain and Syndrome, are not specific types of illnesses but rather symptoms or clinical manifestations that can occur in various health conditions.

3. A client is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include in the care plan?

• A. Perform an ECG every 12 hours.
• B. Place the client in a supine position while resting.
• C. Draw a troponin level every 4 hours.
• D. Obtain a cardiac rehabilitation consultation.

Correct answer: D

Rationale: After an acute myocardial infarction, cardiac rehabilitation is crucial for the client's recovery. It helps improve the client's overall cardiovascular health, reduces the risk of future cardiac events, and promotes a healthy lifestyle. The other options do not directly address the importance of cardiac rehabilitation in the client's recovery process.

4. When preparing to administer an IM injection that is irritating to the subcutaneous tissue, what is the best action to prevent tracking of the medication?

• A. Use a small gauge needle
• B. Apply ice on the injection site
• C. Administer at a 45° angle
• D. Use the Z-track technique

Correct answer: D

Rationale: The Z-track technique is the best action to prevent tracking of the medication when administering an IM injection that is irritating to the subcutaneous tissue. This technique involves pulling the skin to the side before administering the injection and then releasing the skin after the injection. By doing so, a zig-zag pathway is created, preventing the medication from leaking into the subcutaneous tissue and reducing irritation. Options A, B, and C are incorrect. Using a small gauge needle may not prevent tracking of the medication. Applying ice on the injection site or administering at a 45° angle does not specifically address preventing tracking of the medication in cases where the injection is irritating to the subcutaneous tissue.

5. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

• A. Notify the provider.
• B. Administer heparin via IV infusion.
• C. Administer oxygen therapy.
• D. Obtain a spiral CT scan.

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

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