Nursing Elites

1. The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. What action should the nurse take?

• A. Encourage the UAP to remain in the client's room until the hand rub is completed.
• B. Explain that the hand rub can be completed in less than 2 minutes.
• C. Inform the UAP that handwashing helps to promote better asepsis.
• D. Determine why the UAP was not wearing gloves in the client's room.

Correct answer: B

Rationale: The correct answer is B. Alcohol-based hand rubs are effective with a shorter rub time, typically around 20-30 seconds. Standing at the bedside for 2 minutes to rub hands thoroughly is unnecessary and can lead to wastage of resources. It's essential for the nurse to educate the UAP on proper hand hygiene techniques to ensure efficient and effective infection control practices. Choices A, C, and D are incorrect because encouraging the UAP to remain in the client's room, discussing handwashing instead of hand rubs, and questioning glove use are not the most appropriate actions in this scenario.

2. 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.

3. The nurse is caring for a client with end-stage renal disease (ESRD) who is scheduled for hemodialysis. Which assessment finding is most concerning?

• A. Blood pressure of 110/70 mmHg
• B. Heart rate of 110 beats per minute
• C. Fever of 100.4°F
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A fever of 100.4°F is the most concerning assessment finding in a client with ESRD scheduled for hemodialysis. This elevation in temperature may indicate an underlying infection, which can lead to serious complications in individuals with compromised renal function. Prompt intervention is necessary to prevent the spread of infection and deterioration of the client's condition. The other vital signs mentioned, such as blood pressure, heart rate, and respiratory rate, while important to monitor, are within acceptable ranges and do not pose an immediate threat like a fever indicative of infection.

4. During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 F. Which intervention should the nurse implement?

• A. Stop the transfusion and start a saline infusion.
• B. Administer antipyretics and continue the transfusion.
• C. Monitor the client’s vital signs every 15 minutes.
• D. Notify the healthcare provider and continue the transfusion.

Correct answer: A

Rationale: An increase in temperature during a transfusion may indicate a transfusion reaction, which can be serious. Stopping the transfusion and starting a saline infusion is the priority action to prevent further complications and address the potential adverse reaction. Administering antipyretics (choice B) may mask the symptoms of a transfusion reaction, delaying appropriate treatment. While monitoring vital signs (choice C) is important, stopping the transfusion takes precedence to prevent harm. Notifying the healthcare provider (choice D) is essential but should not delay the immediate intervention of stopping the transfusion and starting a saline infusion.

5. A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnosed osteoporosis. What instruction should the nurse include in the client's teaching plan?

• A. Take on an empty stomach with a full glass of water.
• B. Take with food to avoid stomach upset.
• C. Take before bedtime with a light snack.
• D. Take with milk to enhance absorption.

Correct answer: A

Rationale: The correct answer is to take alendronate on an empty stomach with a full glass of water. This instruction is essential to ensure proper absorption and prevent esophageal irritation. Taking alendronate with food, before bedtime with a light snack, or with milk can interfere with its absorption and effectiveness, leading to potential side effects or reduced therapeutic benefits.

Similar Questions