Nursing Elites

1. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?

• A. Donning sterile gown and gloves to remove the wound dressing
• B. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
• C. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
• D. Donning clean goggles, gown, and gloves to dress the wound

Correct answer: C

Rationale: Choice C is the correct answer. When performing a sterile dressing change, it is essential to use clean gloves to remove soiled dressings and sterile gloves and supplies for applying the new dressing. This helps maintain aseptic technique and reduce the risk of introducing pathogens to the wound. Choices A, B, and D involve incorrect use of sterile and clean supplies, which can compromise the sterility of the procedure and increase the risk of infection.

2. A nurse enters a client's room and finds the client pulseless. The client's living will requests no resuscitation be performed, but the provider has not written the prescription. Which of the following actions should the nurse take?

• A. Administer emergency medications without performing CPR
• B. Begin CPR
• C. Call the provider for a do-not-resuscitate (DNR) order
• D. Respect the client's wishes, and do not attempt CPR

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to begin CPR. In the absence of a written DNR order by the provider, the nurse is ethically and legally obligated to initiate CPR to attempt to save the client's life. Administering emergency medications without CPR (Choice A) may not address the immediate need for life-saving measures. Calling the provider for a DNR order (Choice C) may cause a delay in providing necessary resuscitative measures. Respecting the client's wishes and not attempting CPR (Choice D) goes against the nurse's duty to provide immediate life-saving interventions in the absence of a DNR order.

3. The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions?

• A. Teaches the patient about good nutrition.
• B. Disposes of an uncapped needle in the designated container.
• C. Wears eyewear when emptying the urinary drainage bag.
• D. Dons gloves when wearing artificial nails.

Correct answer: C

Rationale: The correct understanding of standard precautions includes wearing appropriate personal protective equipment to prevent exposure to body fluids. Wearing eyewear when emptying the urinary drainage bag is crucial as it protects the nurse's eyes from potential splashes of body fluids. Teaching the patient about good nutrition (Choice A) is important for overall health but is not directly related to standard precautions. Disposing of an uncapped needle correctly (Choice B) is part of safe needle handling but does not specifically relate to standard precautions. Donning gloves when wearing artificial nails (Choice D) is not a correct understanding of standard precautions, as artificial nails can harbor microorganisms and increase the risk of infection transmission.

4. A patient is experiencing shortness of breath. What is the nurse's immediate action?

• A. Assist the patient into a high Fowler's position.
• B. Administer oxygen at 2 liters per minute via nasal cannula.
• C. Encourage the patient to take deep breaths and cough.
• D. Assess the patient's lung sounds.

Correct answer: B

Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.

5. A client reports pain and swelling at the IV site. What should the nurse do first?

• A. Flush the IV line and continue the infusion.
• B. Stop the infusion and notify the healthcare provider.
• C. Increase the IV infusion rate to reduce discomfort.
• D. Apply a warm compress to the IV site and continue monitoring.

Correct answer: B

Rationale: The correct answer is B: Stop the infusion and notify the healthcare provider. Pain and swelling at an IV site can indicate infiltration or infection, which are serious complications. Stopping the infusion helps prevent further harm to the client, and notifying the healthcare provider promptly allows for appropriate assessment and intervention. Choice A is incorrect because flushing the IV line and continuing the infusion could exacerbate the issue. Choice C is incorrect as increasing the IV infusion rate is not the appropriate action for pain and swelling at the site. Choice D is incorrect because applying a warm compress may not address the underlying issue of infiltration or infection; it's crucial to stop the infusion and seek further guidance.

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