Nursing Elites

1. Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?

• A. Opening the patient’s window to the outside environment
• B. Turning on the patient’s room ventilator
• C. Opening the door of the patient’s room leading into the hospital corridor
• D. Failing to wear gloves when administering a bed bath

Correct answer: D

Rationale: Failure to wear gloves during a bed bath can potentially introduce pathogens, compromising the sterile technique necessary for respiratory isolation. Proper hand hygiene and personal protective equipment are crucial to prevent the transmission of infectious agents in such settings.

2. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?

• A. Arrange for an ethics committee meeting to address the family's concerns.
• B. Support the family's decision and initiate life-sustaining measures.
• C. Complete an incident report.
• D. Encourage the family to contact an attorney.

Correct answer: A

Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.

3. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?

• A. Side rails are ineffective
• B. Side rails should not be used
• C. Side rails are a deterrent that prevents a patient from falling out of bed
• D. Side rails are a reminder to a patient not to get out of bed

Correct answer: D

Rationale: The correct conclusion drawn from the study is that side rails serve as a reminder to the patient not to get out of bed rather than being a fail-proof preventive measure against falls. While they may not entirely prevent falls, they play a role in prompting the patient to be cautious when moving.

4. A patient requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?

• A. Diabetes mellitus
• B. Shoulder presentation
• C. Postterm with oligohydramnios
• D. Chorioamnionitis

Correct answer: C

Rationale: Postterm pregnancy with oligohydramnios is a contraindication for the use of oxytocin due to the increased risk of uterine hyperstimulation and fetal distress. Oxytocin can further stress the fetus in this scenario, potentially leading to adverse outcomes. Therefore, it is crucial for the nurse to recognize this contraindication to ensure the safety of both the mother and the baby during labor.

5. Parenteral penicillin can be administered as an:

• A. IM injection or an IV solution
• B. IV or an intradermal injection
• C. Intradermal or subcutaneous injection
• D. IM or a subcutaneous injection

Correct answer: A

Rationale: Penicillin can be administered intramuscularly or intravenously.

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