Nursing Elites

1. At the surgical scrub sink, a surgical nurse demonstrated the proper surgical handwashing technique by scrubbing:

• A. With her hands held lower than her elbows
• B. With her hands held higher than her elbows
• C. With her hands in a fist position
• D. With hands placed on her chest

Correct answer: B

Rationale: The correct technique for surgical handwashing involves scrubbing with hands held higher than the elbows. This positioning helps prevent water from the contaminated area (the hands) from flowing towards the cleaner area (the elbows). This directional flow minimizes the risk of contaminating the scrubbed hands during the handwashing process. Choices A, C, and D are incorrect: A - having hands lower than elbows would risk contamination of the clean area, C - using a fist position does not ensure proper coverage and thorough handwashing, and D - placing hands on the chest is not part of the proper surgical handwashing technique.

2. A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?

• A. “Get up and change positions slowly.”
• B. “Avoid eating aged cheese and smoked meat.”
• C. “Report any unusual bruising or bleeding to the doctor immediately.”
• D. “Eat the same amount of foods that contain vitamin K every day.”

Correct answer: A

Rationale: The correct instruction for the nurse to give the client who is starting on antihypertensive medication is to 'Get up and change positions slowly.' Antihypertensive medications can cause orthostatic hypotension, a drop in blood pressure when changing positions, so changing positions slowly helps prevent this adverse effect. Choice B about avoiding aged cheese and smoked meat is more relevant for clients taking monoamine oxidase inhibitors (MAOIs) due to potential interactions. Choice C regarding reporting unusual bruising or bleeding is more applicable for clients on anticoagulants. Choice D about consuming consistent amounts of vitamin K-containing foods daily is important for clients taking warfarin, not antihypertensive medications.

3. A healthcare professional is collecting a urine specimen for a client to test via urine dipstick to determine the urine's specific gravity. The healthcare professional knows the result will indicate the amount of:

• A. Solutes in the urine
• B. Bacteria in the urine
• C. pH level of the urine
• D. Glucose in the urine

Correct answer: A

Rationale: Specific gravity measures the concentration of solutes in the urine, reflecting the kidney's ability to concentrate or dilute urine. Choice B, bacteria in the urine, is incorrect because specific gravity does not measure bacterial presence. Choice C, pH level of the urine, is incorrect as it refers to the acidity or alkalinity of the urine, not its specific gravity. Choice D, glucose in the urine, is incorrect as specific gravity does not directly measure glucose levels in urine.

4. A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

• A. Updating the plan of care for a client who is postoperative
• B. Reinforcing teaching with a client who is learning to walk using a quad cane
• C. Reapplying a condom catheter for a client who has urinary incontinence
• D. Applying a sterile dressing to a pressure injury

Correct answer: C

Rationale: The correct answer is C - 'Reapplying a condom catheter for a client who has urinary incontinence.' This task falls within the scope of duties for an assistive personnel (AP). Updating care plans (Choice A), reinforcing teaching (Choice B), and applying sterile dressings (Choice D) typically require a higher level of training and expertise, making them tasks that should not be assigned to an AP. Assigning appropriate tasks based on skill levels ensures safe and effective patient care.

5. A client has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?

• A. Wear gloves when changing the client's gown.
• B. Use hand sanitizer after contact with the client.
• C. Wear a mask when entering the client's room.
• D. Clean the room with a disinfectant spray.

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile in contact isolation is to wear gloves when changing the client's gown. Clostridium difficile is highly transmissible, and wearing gloves helps prevent the spread of the infection. Using hand sanitizer after contact with the client (Choice B) is not enough to prevent the transmission of C. difficile, as the spores can persist and spread. Wearing a mask when entering the client's room (Choice C) is not necessary for C. difficile transmission, which primarily occurs through contact with contaminated surfaces. Cleaning the room with a disinfectant spray (Choice D) is important, but wearing gloves during direct care is the priority to prevent the nurse from acquiring and spreading the infection.

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