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 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.

2. A healthcare professional is preparing to insert an IV catheter into a client’s arm prior to initiating IV fluid therapy. Which of the following interventions should the healthcare professional implement to prevent infection?

• A. Thread the catheter up to the hub
• B. Use a sterile technique throughout the procedure
• C. Clean the insertion site with alcohol only
• D. Use gloves but not a mask during the procedure

Correct answer: B

Rationale: Using a sterile technique throughout the procedure is essential to prevent infection when inserting an IV catheter. This includes maintaining aseptic conditions, using sterile equipment, and following proper hand hygiene practices. Choice A is incorrect because threading the catheter up to the hub does not specifically address infection prevention. Choice C is incorrect as cleaning the insertion site with alcohol only may not provide adequate disinfection, as it is essential to use an antiseptic solution to reduce microbial load. Choice D is incorrect as wearing gloves alone is not sufficient protection against infection; a mask should also be worn to prevent the spread of microorganisms through respiratory secretions.

3. A healthcare professional is caring for a client who has a prescription for morphine 5mg IM but accidentally administers the entire 10mg from the single-dose vial. Which of the following actions should the healthcare professional take first?

• A. Complete an incident report
• B. Measure the client’s respiratory rate
• C. Report the incident to the pharmacy
• D. Notify the client's provider

Correct answer: B

Rationale: Assessing the client's respiratory rate is the priority in this situation as overdosing on morphine can lead to respiratory depression, making it crucial to monitor the client's breathing. Completing an incident report (choice A) is important but should not be the first action. Reporting the incident to the pharmacy (choice C) and notifying the client's provider (choice D) are necessary steps but assessing the client's respiratory status takes precedence to ensure immediate safety and intervention.

4. The healthcare provider is monitoring a client in active labor. Which pattern on the fetal heart monitor requires immediate intervention?

• A. Early decelerations
• B. Late decelerations
• C. Accelerations
• D. Moderate variability

Correct answer: B

Rationale: Late decelerations are concerning as they indicate uteroplacental insufficiency, potentially resulting in fetal hypoxia. Immediate intervention is necessary to address the underlying cause and ensure fetal well-being. Early decelerations are typically benign and associated with head compression during contractions. Accelerations are reassuring and indicate fetal well-being. Moderate variability is a normal finding and indicates a healthy autonomic nervous system response. Therefore, late decelerations (Choice B) require immediate attention, while the other patterns are generally considered normal or benign during labor.

5. A healthcare provider is preparing to provide hygiene care. Which principle should the provider consider when planning hygiene care?

• A. Hygiene care is not performed in the same way by all individuals.
• B. No two individuals perform hygiene in the same manner.
• C. Standardizing a patient's hygienic practices is crucial.
• D. Understanding patient needs is not essential during hygiene care.

Correct answer: B

Rationale: The correct answer is B: 'No two individuals perform hygiene in the same manner.' It is crucial to individualize a patient's care based on understanding the patient's unique hygiene practices and preferences. Choice A is incorrect because hygiene care should be tailored to the individual's needs and preferences, not seen as routine and expected for everyone. Choice C is incorrect as standardizing a patient's hygienic practices may not address their specific needs. Choice D is incorrect because understanding patient needs is essential during hygiene care to provide personalized and effective care.

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