Nursing Elites

1. 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.

2. UAP has lowered the head of the bed to change the linens for a client who is bedridden. Which observation...most immediate intervention by the nurse?

• A. A feeding is infusing at 40 mL/hr through an enteral feeding tube.
• B. The urine meter attached to the urinary drainage bag is completely full.
• C. There is a large dependent loop in the client's urinary drainage tubing.
• D. Purulent drainage is present around the insertion site of the feeding tube.

Correct answer: D

Rationale: The correct answer is D. Purulent drainage around the insertion site of the feeding tube indicates an infection, which requires immediate attention. This may be a sign of a serious complication that needs prompt nursing intervention to prevent further complications or deterioration in the client's condition. Choices A, B, and C do not indicate an immediate threat to the client's health. While option A highlights the infusion rate of the feeding, it does not pose an immediate risk compared to the presence of purulent drainage indicating infection.

3. A healthcare professional reviewing a client’s health record notes a new prescription for lisinopril 10 mg PO once daily. The healthcare professional should identify this as which of the following types of prescription?

• A. Single
• B. Stat
• C. Routine
• D. Now

Correct answer: C

Rationale: A prescription for once-daily medication is considered routine as it is meant for regular, daily administration to maintain therapeutic levels in the body. Single prescriptions are for one-time use only. Stat prescriptions are for immediate administration in urgent situations, while now prescriptions are also for immediate use but may have varying levels of urgency depending on the patient's condition. In this case, since the prescription is for once daily use, it falls under the category of routine prescription.

4. A client expresses pain during dressing changes postoperatively. Which intervention should the nurse prioritize?

• A. Encourage the client to relax and take deep breaths during the dressing change.
• B. Educate the client about the importance of pain management postoperatively.
• C. Assist the client to a comfortable position for the dressing change.
• D. Administer pain medication 45 minutes before changing the client's dressing.

Correct answer: D

Rationale: The priority action for the nurse is to address the client's immediate physiological need for comfort and pain relief during the dressing change. Administering pain medication 45 minutes before the procedure can help alleviate the pain experienced by the client. Encouraging relaxation techniques (choice A) is beneficial but may not provide sufficient pain relief during the dressing change. Educating about the importance of pain management (choice B) is relevant but does not address the immediate need for pain relief. Assisting the client to a comfortable position (choice C) is helpful but does not directly address the client's pain concern during the dressing change. Administering pain medication is the most direct and effective intervention to ensure optimal client comfort and compliance with necessary procedures.

5. 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 technique?

• A. The nurse washes with her hands held higher than her elbows.
• B. The nurse uses an alcohol-based hand rub for 30 seconds.
• C. The nurse scrubs hands and forearms for 2 minutes with soap and water.
• D. The nurse washes her hands with soap and water for only 15 seconds.

Correct answer: A

Rationale: Proper surgical hand-washing technique involves washing with the hands held higher than the elbows. This positioning is essential to ensure proper rinsing and to prevent the risk of contamination. Option B, using an alcohol-based hand rub for 30 seconds, is not specific to surgical hand-washing and is more commonly used for routine hand hygiene. Option C, scrubbing hands and forearms for 2 minutes with soap and water, is excessive and not typically required for routine hand-washing. Option D, washing hands with soap and water for only 15 seconds, is insufficient for thorough surgical hand-washing.

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