Nursing Elites

1. A healthcare professional is preparing to administer medications to a client. Which of the following client identifiers should the healthcare professional use to ensure medication safety?

• A. Ask the client to state their full name.
• B. Ask the client for their date of birth.
• C. Compare the client's wristband with the medication administration record.
• D. Ask the client for their room number.

Correct answer: C

Rationale: Comparing the client's wristband with the medication administration record is a crucial step in ensuring medication safety. The wristband typically contains unique identifiers such as the client's name, date of birth, and medical record number, which should be cross-checked with the medication administration record to confirm the correct patient. Asking the client to state their name (Choice A) or date of birth (Choice B) may not be as reliable as the information can be misunderstood or miscommunicated. Asking for the room number (Choice D) is not a reliable client identifier for medication administration and does not confirm the patient's identity accurately.

2. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

• A. Perform hand hygiene
• B. Identify the client using two identifiers
• C. Prepare the sterile field
• D. Don sterile gloves

Correct answer: A

Rationale: Performing hand hygiene is essential before any direct patient care procedure to prevent the spread of infection. Proper hand hygiene helps reduce the risk of introducing harmful microorganisms to the client, especially when dealing with a procedure like tracheostomy care. Identifying the client, preparing the sterile field, and donning sterile gloves are all important steps in tracheostomy care, but hand hygiene precedes them to maintain asepsis and ensure patient safety.

3. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

• A. Obtaining cotton balls for the tracheostomy care
• B. Using a sterile water bottle
• C. Checking the suction equipment
• D. Wearing a sterile gown

Correct answer: A

Rationale: The correct answer is A. Obtaining cotton balls for tracheostomy care is not recommended due to the risk of fiber contamination. Sterile gauze should be used instead. Choice B, using a sterile water bottle, is a correct and appropriate action for tracheostomy care to maintain cleanliness. Choice C, checking the suction equipment, is also a necessary step to ensure it is functioning properly for the procedure. Choice D, wearing a sterile gown, is a standard precaution to maintain a sterile environment during tracheostomy care.

4. A client requires gastric decompression, and a nurse is inserting an NG tube. Which action should the nurse take to verify proper placement of the tube?

• A. Assess the client for a gag reflex
• B. Measure the pH of the gastric aspirate
• C. Place the end of the NG tube in water to observe for bubbling
• D. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water

Correct answer: B

Rationale: Measuring the pH of the gastric aspirate is the most reliable method to confirm proper placement of an NG tube. Gastric fluid has an acidic pH, typically ranging from 1 to 5. Assessing the client for a gag reflex (choice A) is important for airway protection but does not confirm tube placement. Placing the NG tube in water to observe for bubbling (choice C) is incorrect and not a reliable method for verifying placement. Auscultating 2.5 cm above the umbilicus while injecting sterile water (choice D) is an outdated method and is not recommended for verifying NG tube placement.

5. What is the most important action for preventing infection in a client with a central venous catheter?

• A. Changing the catheter dressing every 72 hours.
• B. Flushing the catheter with heparin solution daily.
• C. Ensuring the catheter is clamped when not in use.
• D. Maintaining sterile technique when handling the catheter.

Correct answer: D

Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. This action helps minimize the introduction of pathogens into the catheter site, reducing the risk of contamination and subsequent infection. Changing the catheter dressing every 72 hours, while important, does not directly address the prevention of infection at the insertion site. Flushing the catheter with heparin solution daily helps prevent occlusion but does not primarily focus on infection prevention. Ensuring the catheter is clamped when not in use is essential for preventing air embolism but does not directly relate to infection control.

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