Nursing Elites

1. The nurse is performing hand hygiene before assisting a healthcare provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next?

• A. Repeat handwashing using antiseptic soap.
• B. Inform the healthcare provider and recruit another nurse to assist.
• C. Extend the handwashing procedure to 5 minutes.
• D. Rinse and dry hands and begin assisting the healthcare provider.

Correct answer: A

Rationale: The correct answer is A. The sink is considered a contaminated area. When hand hygiene is compromised during the process, it is essential to repeat handwashing using antiseptic soap to ensure proper hygiene. Choice B is incorrect because the situation can be managed by proper handwashing. Choice C is incorrect as extending the handwashing procedure to 5 minutes is not necessary in this scenario. Choice D is incorrect as the hands need to be properly cleaned before assisting the healthcare provider.

2. What is the priority intervention for a patient experiencing chest pain?

• A. Administer nitroglycerin as prescribed.
• B. Encourage the patient to take deep breaths.
• C. Monitor the patient's blood pressure closely.
• D. Encourage the patient to rest in a comfortable position.

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin as prescribed. Nitroglycerin helps relieve chest pain by dilating blood vessels and improving blood flow, addressing the immediate concern of chest pain. Encouraging deep breaths may not be appropriate for chest pain, monitoring blood pressure, although important, is not the priority when the patient is experiencing chest pain, and while resting in a comfortable position is beneficial, administering nitroglycerin is the priority intervention to address the chest pain.

3. What is the priority nursing intervention for a patient with a new tracheostomy?

• A. Suction the tracheostomy as needed to maintain a patent airway.
• B. Monitor the patient's oxygen saturation.
• C. Provide humidified air to prevent drying of the airway.
• D. Administer pain medication as prescribed.

Correct answer: A

Rationale: The correct answer is to suction the tracheostomy as needed to maintain a patent airway. After a tracheostomy procedure, the immediate concern is airway patency to prevent respiratory compromise. Suctioning helps clear secretions and maintains a clear airway, reducing the risk of respiratory distress. Monitoring the patient's oxygen saturation (choice B) is important but not the priority compared to ensuring a clear airway. Providing humidified air (choice C) and administering pain medication (choice D) are also essential aspects of care for a patient with a tracheostomy, but they are not the priority when immediate airway management is required.

4. Which of the following clients requiring crutches should a nurse teach about how to use a three-point gait?

• A. A client who has a right femur fracture with no weight-bearing on the affected leg
• B. A client who has bilateral leg braces due to paralysis of the lower extremities
• C. A client who has bilateral knee replacements with partial weight-bearing on both legs
• D. A client who is able to bear full weight on both lower extremities

Correct answer: A

Rationale: A three-point gait is recommended for clients who are non-weight bearing on one leg. In this case, a client with a right femur fracture requiring no weight-bearing on the affected leg would benefit from learning how to use a three-point gait. Choices B, C, and D are incorrect because they involve clients who have varying degrees of weight-bearing ability on both legs, which would not require the use of a three-point gait.

5. A nurse is preparing to administer medication to a client by nasogastric tube. What should the nurse do first?

• A. Administer the medication without further assessment.
• B. Check the tube placement before administering any medication.
• C. Administer the medication in liquid form only.
• D. Administer half the dosage as a precaution.

Correct answer: B

Rationale: The correct answer is B: Check the tube placement before administering any medication. Before administering medication through a nasogastric tube, the nurse must first verify the tube's correct placement to ensure the medication reaches the stomach and to prevent complications such as aspiration. Options A, C, and D are incorrect because administering medication without confirming proper tube placement can lead to serious consequences for the client.

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