Nursing Elites

1. After routine patient contact, how long should hand washing last at least?

• A. 30 seconds
• B. 1 minute
• C. 2 minutes
• D. 3 minutes

Correct answer: A

Rationale: Proper hand washing for 30 seconds is recommended after routine patient contact as it effectively removes pathogens. This duration ensures thorough cleaning without excessive time consumption, promoting infection control and prevention.

2. A client is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

• A. Dehydration is treated with calcium supplements.
• B. Dehydration can increase the risk of preterm labor.
• C. Dehydration is associated with gastroesophageal reflux.
• D. Dehydration is caused by decreased hemoglobin and hematocrit.

Correct answer: B

Rationale: Dehydration can lead to an imbalance in electrolytes and cause uterine irritability, potentially leading to preterm contractions. It is essential for the nurse to educate the client on the importance of adequate hydration to reduce the risk of preterm labor. The statement 'Dehydration can increase the risk of preterm labor' directly addresses the client's condition and provides relevant information for their understanding and management of the situation.

3. During the removal of a chest tube, what should the nurse instruct the client to do?

• A. Lie on their left side.
• B. Use the incentive spirometer.
• C. Cough at regular intervals.
• D. Perform the Valsalva maneuver.

Correct answer: D

Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.

4. When planning care for a client on mechanical ventilation, which mode of ventilation that increases the effort of the client's respiratory muscles should NOT be included in the plan of care?

• A. Assist-control
• B. Synchronized intermittent mandatory ventilation
• C. Continuous positive airway pressure
• D. Pressure support ventilation

Correct answer: A

Rationale: Assist-control ventilation mode delivers a preset tidal volume at a set rate; however, it may not be suitable for clients who need to maintain some level of respiratory muscle activity. This mode provides full support for each breath, potentially leading to decreased respiratory muscle strength over time. Therefore, it is important to avoid using assist-control mode for clients who require increased effort of respiratory muscles to prevent muscle atrophy and promote optimal respiratory function.

5. 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.

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