Nursing Elites

1. According to the principle of asepsis, which situation should the PN consider to be sterile?

• A. A one-inch border around the edges of a sterile field set up in the operating room
• B. A sterile glove that the PN thinks might have touched hair
• C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp table top
• D. An open sterile Foley catheter kit set up on a table at the PN's waist level

Correct answer: A

Rationale: According to the principle of asepsis, the one-inch border around the edges of a sterile field set up in the operating room is considered non-sterile, while the central area remains sterile. Therefore, the PN should consider the situation described in choice A to be sterile. Choice B is incorrect because a glove that may have touched hair is contaminated. Choice C is incorrect as a sterile item placed on a damp surface is considered contaminated. Choice D is incorrect as a sterile kit set up at the PN's waist level is prone to contamination.

2. Which of the following is a priority for the nurse to include in the teaching of a client who was recently prescribed alprazolam (Xanax) as an oral medication?

• A. Monitor heart rate before taking the medication
• B. Monitor temperature daily
• C. Avoid unprotected exposure to sunlight
• D. Avoid alcohol

Correct answer: D

Rationale: The correct answer is D: 'Avoid alcohol.' Alprazolam (Xanax) can have central nervous system depressant effects, which are exacerbated by alcohol. It is crucial to avoid alcohol while taking this medication to prevent severe sedation and respiratory depression. Monitoring heart rate (choice A) is not directly related to alprazolam administration. Monitoring temperature daily (choice B) is not a priority teaching point for a client prescribed alprazolam. Avoiding unprotected exposure to sunlight (choice C) is not specifically linked to the use of alprazolam.

3. Which of the following is the most effective way to prevent the spread of infection in a healthcare setting?

• A. Using sterile gloves
• B. Wearing a face mask
• C. Performing hand hygiene
• D. Using disposable equipment

Correct answer: C

Rationale: Performing hand hygiene is the most effective way to prevent the spread of infection in a healthcare setting. Hand hygiene helps remove pathogens that could be transmitted through direct contact, making it a crucial practice in infection control. While using sterile gloves and disposable equipment are important in certain situations, they do not address the potential transmission of pathogens through direct contact, unlike hand hygiene. Wearing a face mask is important for respiratory precautions but may not be as effective as hand hygiene in preventing the spread of infections through direct contact.

4. A client with a prescription for a transcutaneous electrical nerve stimulator (TENS) unit for pain management asks how it works. What information should the nurse reinforce?

• A. The discharge of electricity will distract the client's focus from the pain
• B. An infusion of medication in the spinal canal will block pain perception
• C. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
• D. A mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain

Correct answer: D

Rationale: The correct answer is D. TENS works by delivering a mild electrical stimulus that can block pain signals from reaching the brain, effectively reducing the perception of pain. Choice A is incorrect because TENS does not distract from pain but rather interferes with pain signals. Choice B is incorrect as TENS does not involve infusing medication into the spinal canal. Choice C is also incorrect because TENS does not target the cerebral cortex to dull pain perception but rather works at the level of nerve conduction.

5. The nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate?

• A. They are irregular
• B. They are usually felt in the abdomen
• C. They start in the back and radiate to the abdomen
• D. They become more intense during walking

Correct answer: B

Rationale: The correct statement about prelabor contractions (Braxton Hicks contractions) is that they are usually felt in the abdomen. They are irregular in nature and do not intensify with movement. Choice A is incorrect because prelabor contractions are irregular, not regular. Choice C is incorrect as prelabor contractions do not start in the back and radiate to the abdomen. Choice D is incorrect as prelabor contractions do not become more intense during walking.

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