Nursing Elites

1. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?

• A. Ask a more experienced nurse to perform that scrub since it is the first time of the day
• B. Validate the nurse is implementing the OR policy for surgical hand scrub
• C. Inform the nurse that hand scrubs should be 3 minutes between cases.
• D. Direct the nurse to continue the surgical hand scrub for a 5-minute duration.

Correct answer: D

Rationale: The correct answer is to direct the nurse to continue the surgical hand scrub for a 5-minute duration. Surgical hand scrubs should last for 5 to 10 minutes, ensuring thorough cleaning and disinfection. Choice A is incorrect because the nurse should be guided to complete the scrub properly rather than having someone else do it. Choice B is incorrect as it does not address the duration of the hand scrub. Choice C is incorrect as it suggests a 3-minute hand scrub is sufficient, which is inadequate for proper preparation before surgery.

2. The nurse is preparing to administer an enema to a client with severe constipation. Which position is most appropriate for the client?

• A. Supine with the head elevated 30 degrees
• B. Left lateral with the right leg flexed
• C. Sims’ position with the right leg flexed
• D. Prone position with the head turned to the side

Correct answer: C

Rationale: Sims’ position with the right leg flexed is the most appropriate position for administering an enema to a client with severe constipation. This position helps in promoting the flow of the enema solution into the rectum and facilitates the evacuation of stool. Supine position with the head elevated 30 degrees (Choice A) is not ideal for administering an enema as it does not facilitate the flow of the solution. Left lateral position with the right leg flexed (Choice B) is not the best choice for administering an enema. Prone position with the head turned to the side (Choice D) is also not suitable for administering an enema as it does not assist in the proper administration and retention of the solution.

3. The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

• A. Evaluate the oxygen saturation.
• B. Administer a bronchodilator.
• C. Assist the client to sit upright.
• D. Encourage slow, deep breathing.

Correct answer: A

Rationale: In this scenario, the nurse should first evaluate the oxygen saturation. This action is crucial as it provides immediate information on the client's respiratory status. Assessing the oxygen saturation can help determine the adequacy of oxygenation and guide further interventions. Administering a bronchodilator (Choice B) may be necessary based on assessment findings, but it should not be the first action without knowing the oxygen saturation level. While assisting the client to sit upright (Choice C) is generally beneficial for respiratory function, in this case, assessing oxygen saturation takes precedence. Encouraging slow, deep breathing (Choice D) can be helpful, but it is secondary to evaluating the oxygen saturation in this situation.

4. When organizing home visits for the day, which older client should the home health nurse plan to visit first?

• A. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools.
• B. A man who receives weekly injections of epoetin (Procrit) for a low serum iron level.
• C. A man with emphysema who smokes and is complaining of white patches in his mouth.
• D. A frail woman with heart failure who reported a 2-pound weight gain in the last week.

Correct answer: A

Rationale: The correct answer is A. Dark, tarry stools may indicate gastrointestinal bleeding, a potentially life-threatening condition that requires immediate attention. Visiting this client first is crucial for prompt assessment and intervention. Choices B, C, and D do not present immediate life-threatening conditions that require urgent attention compared to the potential emergency indicated by dark, tarry stools.

5. A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

• A. Describe the transmission of drugs to the infant through breast milk
• B. Encourage her to use stress-relieving alternatives, such as deep breathing exercises
• C. Inform her that some antianxiety medications are safe to take while breastfeeding
• D. Explain that anxiety is a normal response for the mother of a 3-week-old.

Correct answer: C

Rationale: There are several antianxiety medications that are not contraindicated for breastfeeding mothers, so it is important to inform her of this option.

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