Nursing Elites

1. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?

• A. Ask a more experienced nurse to perform that scrub since it is the first time of the day
• B. Validate the nurse is implementing the OR policy for surgical hand scrub
• C. Inform the nurse that hand scrubs should be 3 minutes between cases.
• D. Direct the nurse to continue the surgical hand scrub for a 5-minute duration.

Correct answer: D

Rationale: The correct answer is to direct the nurse to continue the surgical hand scrub for a 5-minute duration. Surgical hand scrubs should last for 5 to 10 minutes, ensuring thorough cleaning and disinfection. Choice A is incorrect because the nurse should be guided to complete the scrub properly rather than having someone else do it. Choice B is incorrect as it does not address the duration of the hand scrub. Choice C is incorrect as it suggests a 3-minute hand scrub is sufficient, which is inadequate for proper preparation before surgery.

2. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which assessment finding is most concerning?

• A. INR of 3.5
• B. Prothrombin time (PT) of 15 seconds
• C. Headache
• D. Blood pressure of 140/90 mmHg

Correct answer: C

Rationale: The correct answer is C. A headache in a client with a history of atrial fibrillation receiving warfarin (Coumadin) is concerning as it may indicate bleeding, which requires immediate assessment and intervention. Headaches can be a symptom of increased intracranial pressure due to bleeding, especially in patients on anticoagulants. Options A and B are within acceptable ranges for a client on warfarin therapy, indicating that the medication is effectively managing the clotting times. Option D, a blood pressure of 140/90 mmHg, while elevated, is not directly related to the client's condition of atrial fibrillation and warfarin therapy.

3. During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 F. Which intervention should the nurse implement?

• A. Stop the transfusion and start a saline infusion.
• B. Administer antipyretics and continue the transfusion.
• C. Monitor the client’s vital signs every 15 minutes.
• D. Notify the healthcare provider and continue the transfusion.

Correct answer: A

Rationale: An increase in temperature during a transfusion may indicate a transfusion reaction, which can be serious. Stopping the transfusion and starting a saline infusion is the priority action to prevent further complications and address the potential adverse reaction. Administering antipyretics (choice B) may mask the symptoms of a transfusion reaction, delaying appropriate treatment. While monitoring vital signs (choice C) is important, stopping the transfusion takes precedence to prevent harm. Notifying the healthcare provider (choice D) is essential but should not delay the immediate intervention of stopping the transfusion and starting a saline infusion.

4. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse include in the plan of care?

• A. Encourage the client to drink plenty of fluids.
• B. Perform deep suctioning every 2 to 4 hours.
• C. Increase humidity in the client's room.
• D. Administer a mucolytic agent.

Correct answer: C

Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. Encouraging the client to drink plenty of fluids can be beneficial for overall hydration but may not directly address thick secretions. Deep suctioning every 2 to 4 hours can be harmful and cause trauma to the airway lining. Administering a mucolytic agent should be done under the healthcare provider's order and may not be the initial intervention for thick secretions.

5. An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?

• A. Identify pills in the bag
• B. Review the client's medication schedule
• C. Assess the client's symptoms
• D. Educate the client about proper medication usage

Correct answer: A

Rationale: The correct answer is to identify pills in the bag first. This is essential to ensure the client is taking the correct medications and to prevent any potential medication errors. Reviewing the client's medication schedule (choice B) can come after identifying the pills to cross-reference the medications. Assessing the client's symptoms (choice C) is important but should follow identifying the medications. Educating the client about proper medication usage (choice D) is crucial but should be done after confirming the medications in the bag.

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