Nursing Elites

1. A nurse in a surgical suite notes documentation on a client's medical record stating that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

• A. Ensure sterilization of non-disposable items with ethylene oxide
• B. Wrap monitoring cords with stockinette and secure them with non-latex tape
• C. Cleanse latex ports on IV tubing with chlorhexidine before administering medication
• D. Wear hypoallergenic latex gloves that are powder-free

Correct answer: B

Rationale: In this scenario, the nurse should take precautions to prevent latex exposure to the client due to his latex allergy. Wrapping monitoring cords with stockinette and securing them with non-latex tape helps to minimize the risk of latex contact with the client. Choice A is incorrect as sterilizing non-disposable items with ethylene oxide does not specifically address the avoidance of latex exposure. Choice C involves using latex ports on IV tubing, which can pose a risk of allergic reaction in a client with a latex allergy. Choice D suggests wearing latex gloves, even if hypoallergenic, which can still trigger a reaction in individuals with latex allergy. Therefore, the best option is to choose non-latex materials like stockinette and non-latex tape to prevent direct contact with latex.

2. What intervention should be implemented by the LPN to reduce the risk of aspiration in a client with a nasogastric tube receiving continuous enteral feedings?

• A. Elevate the head of the bed to 30-45 degrees.
• B. Check residual volumes every 4 hours.
• C. Verify tube placement every shift.
• D. Flush the tube with water every 4 hours.

Correct answer: A

Rationale: Elevating the head of the bed to 30-45 degrees is crucial in reducing the risk of aspiration because it helps keep the gastric contents lower than the esophagus, thereby promoting proper digestion and preventing reflux. This position also aids in reducing the likelihood of regurgitation and aspiration of gastric contents. Checking residual volumes every 4 hours is important for monitoring feeding tolerance but does not directly address the risk of aspiration. Verifying tube placement every shift is essential for ensuring the tube is correctly positioned within the gastrointestinal tract but does not directly reduce the risk of aspiration. Flushing the tube with water every 4 hours may help maintain tube patency and prevent clogging, but it does not specifically address the risk of aspiration associated with nasogastric tube feedings.

3. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing techniques?

• A. The nurse washes with her hands held higher than her elbows.
• B. The nurse uses a brush to scrub under her nails.
• C. The nurse washes for at least 30 seconds.
• D. The nurse uses alcohol-based hand rub only.

Correct answer: A

Rationale: Proper surgical hand-washing technique involves keeping the hands higher than the elbows to prevent contamination. Washing with hands held lower than the elbows can lead to potential contamination. Using a brush to scrub under the nails is not recommended as it can cause microabrasions, increasing infection risk. While washing for at least 30 seconds is a good practice for thorough hand hygiene, hand positioning is critical during surgical hand-washing. Using alcohol-based hand rub alone is insufficient for surgical hand-washing as it may not effectively remove dirt, debris, and transient microorganisms.

4. A client has a new prescription for a metered-dose inhaler. Which of the following instructions should the nurse include?

• A. Inhale quickly and deeply while pressing down on the inhaler.
• B. Hold your breath for 10 seconds after inhaling the medication.
• C. Exhale immediately after inhaling the medication.
• D. Shake the inhaler before each use.

Correct answer: B

Rationale: The correct instruction for using a metered-dose inhaler is to hold your breath for 10 seconds after inhaling the medication. This allows the medication to be absorbed more effectively in the lungs. Inhaling quickly and deeply while pressing down on the inhaler (Choice A) may cause the medication to deposit in the mouth and throat rather than reaching the lungs. Exhaling immediately after inhaling the medication (Choice C) may also lead to medication wastage. Shaking the inhaler before each use (Choice D) is not necessary for all types of inhalers and can sometimes cause improper drug delivery.

5. A healthcare professional is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the healthcare professional include in the plan?

• A. Empty the drainage bag at least every 8 hours
• B. Keep the drainage bag below the level of the bladder
• C. Use sterile technique to collect a specimen from the drainage system
• D. Secure the catheter to the lower abdomen with a securement device

Correct answer: B

Rationale: The correct action to include in the plan is to keep the drainage bag below the level of the bladder. This positioning helps ensure proper drainage and prevents backflow of urine into the bladder, reducing the risk of urinary tract infections. Emptying the drainage bag regularly is important, typically every 4-8 hours or when it is half-full, to maintain adequate flow and prevent infection (Choice A is incorrect). Using a sterile technique to collect specimens from the drainage system is crucial to prevent introducing pathogens into the urinary tract, so clean technique should not be used (Choice C is incorrect). Taping the catheter to the lower abdomen is not recommended as it can cause tension on the catheter, leading to discomfort and potential trauma to the urethra (Choice D is incorrect).

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