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. After adding feeding solution to a client's tube feeding system as seen in the picture, what action should the PN take next?

• A. Remove the air from the solution bag
• B. Obtain a piston syringe and irrigation set
• C. Record the solution added as fluid intake
• D. Calculate the rate of flow of the solution

Correct answer: B

Rationale: After adding feeding solution, obtaining a piston syringe and irrigation set is necessary to flush the feeding tube and ensure patency before starting the feeding. This helps prevent blockages and ensures proper delivery of the nutritional solution. Option A is incorrect because removing air from the solution bag is not the immediate next step after adding the feeding solution. Option C is incorrect as recording the solution added as fluid intake is important but not the immediate next step. Option D is incorrect as calculating the rate of flow of the solution is not the next step after adding the feeding solution.

3. What is an essential nursing action before administering a blood transfusion?

• A. Checking the patient’s blood pressure
• B. Verifying the blood type and patient identity with another nurse
• C. Flushing the IV line with saline
• D. Administering pre-transfusion medications

Correct answer: B

Rationale: Verifying the blood type and patient identity with another nurse is crucial before administering a blood transfusion. This step helps prevent transfusion reactions and ensures that the correct blood is given to the right patient. Checking the patient’s blood pressure, although important, is not directly related to verifying blood type and patient identity. Flushing the IV line with saline is a good practice but is not as critical as confirming the blood type and patient identity. Administering pre-transfusion medications would come after verifying the blood type and patient identity.

4. A client post-thyroidectomy is being monitored for signs of hypocalcemia. Which of the following symptoms should the nurse be most concerned about?

• A. Tingling in the hands and around the mouth.
• B. Nausea and vomiting.
• C. Constipation.
• D. Bradycardia.

Correct answer: A

Rationale: The correct answer is A: Tingling in the hands and around the mouth. This symptom is a classic sign of hypocalcemia, which can occur after thyroidectomy if the parathyroid glands were inadvertently damaged during surgery. Nausea and vomiting (Choice B) are not specific to hypocalcemia. Constipation (Choice C) is not a typical symptom of hypocalcemia. Bradycardia (Choice D) is more commonly associated with hypothyroidism rather than hypocalcemia.

5. In what order should the PN implement these steps to provide wound care? (Place in correct order.)

• A. Don procedure gloves
• B. Remove the dressing
• C. Apply prescribed medications to the wound
• D. All of the Above

Correct answer: D

Rationale: The correct answer is 'D - All of the Above.' The PN should first don procedure gloves to maintain aseptic technique, then remove the dressing to assess the wound, and finally apply prescribed medications to the wound. This sequence ensures that non-sterile tasks like donning gloves are done before sterile tasks like applying medications, reducing the risk of wound contamination. Choices A, B, and C are all essential steps in providing effective wound care.

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