Nursing Elites

1. According to the principle of asepsis, which situation should the PN consider to be sterile?

• A. A one-inch border around the edges of a sterile field set up in the operating room
• B. A sterile glove that the PN thinks might have touched hair
• C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp table top
• D. An open sterile Foley catheter kit set up on a table at the PN's waist level

Correct answer: A

Rationale: According to the principle of asepsis, the one-inch border around the edges of a sterile field set up in the operating room is considered non-sterile, while the central area remains sterile. Therefore, the PN should consider the situation described in choice A to be sterile. Choice B is incorrect because a glove that may have touched hair is contaminated. Choice C is incorrect as a sterile item placed on a damp surface is considered contaminated. Choice D is incorrect as a sterile kit set up at the PN's waist level is prone to contamination.

2. A client who had a left hemicolectomy is experiencing a low-grade fever on post-operative day three. What is the nurse's best action?

• A. Encourage deep breathing and the use of the incentive spirometer.
• B. Administer antipyretic medication as prescribed.
• C. Notify the healthcare provider immediately.
• D. Increase the client’s fluid intake.

Correct answer: A

Rationale: A low-grade fever on post-operative day three can be a sign of atelectasis, a common post-operative complication. Encouraging deep breathing and the use of the incentive spirometer can help prevent and treat this condition. Atelectasis is often due to shallow breathing, so option A is the best initial action to promote lung expansion. Administering antipyretic medication (option B) may help reduce the fever but does not directly address the underlying cause. Notifying the healthcare provider immediately (option C) is not necessary at this point unless other concerning symptoms are present. Increasing the client’s fluid intake (option D) is important for overall recovery but is not the priority in this scenario.

3. A post-operative client is prescribed sequential compression devices (SCDs) while on bed rest. What is the primary purpose of this device?

• A. To prevent deep vein thrombosis (DVT).
• B. To improve circulation in the legs.
• C. To prevent pressure ulcers.
• D. To alleviate post-operative pain.

Correct answer: A

Rationale: The correct answer is A: 'To prevent deep vein thrombosis (DVT).' Sequential compression devices (SCDs) are primarily used to prevent deep vein thrombosis (DVT) by promoting blood flow in the legs and reducing venous stasis, which is a common risk for post-operative clients who are on bed rest. While SCDs do improve circulation in the legs indirectly, their primary purpose is DVT prevention. Preventing pressure ulcers is typically achieved through repositioning and support surfaces, not with SCDs, making choice C incorrect. SCDs are not used to alleviate post-operative pain, so choice D is also incorrect.

4. Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the PN to ask the child?

• A. How much exercise did the child have today?
• B. Did the child perform a finger stick?
• C. When did the child last urinate?
• D. Has the child eaten recently?

Correct answer: B

Rationale: The correct answer is B: 'Did the child perform a finger stick?' Before administering insulin, it is crucial to check the child's blood glucose level to prevent hypoglycemia. Performing a finger stick blood glucose test provides essential information on the current blood sugar level. Choice A ('How much exercise did the child have today?') is not as critical as monitoring blood glucose levels directly. Choice C ('When did the child last urinate?') is not directly related to the immediate need for insulin administration. Choice D ('Has the child eaten recently?') is important but not as crucial as knowing the current blood glucose level.

5. An older postoperative client has the nursing diagnosis 'impaired mobility related to fear of falling.' Which desired outcome best directs the PN's actions for the client?

• A. The client will ambulate with assistance every 4 hours
• B. The physical therapist will instruct the client in the use of a walker
• C. The client will use self-affirmation statements to decrease fear
• D. The PN will place a gait belt on the client prior to ambulation

Correct answer: C

Rationale: The correct answer is C. Using self-affirmation statements helps the client reduce fear and regain confidence in mobility, which is essential for improving impaired mobility. Choice A focuses more on the frequency of ambulation rather than addressing the fear of falling. Choice B involves the physical therapist and the use of a walker, which may not directly address the client's fear. Choice D is a safety measure but does not specifically target the client's fear of falling.

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