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. The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?

• A. Place the side rails in an up position.
• B. Assist the UAP in turning the client.
• C. Provide instructions on proper bed-making techniques.
• D. Ask the client if they are comfortable.

Correct answer: A

Rationale: Correct Answer: The nurse should first place the side rails in an up position. This action is crucial to prevent the client from falling while the bed is being made. Choice B is incorrect as moving or turning the client is not necessary at this point. Choice C is not a priority when immediate safety concerns are present. Choice D, asking the client if they are comfortable, though important, should come after ensuring the client's safety by raising the side rails.

3. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?

• A. Administer intravenous insulin as prescribed.
• B. Monitor the client's urine output.
• C. Administer intravenous fluids.
• D. Administer 50% dextrose IV push.

Correct answer: A

Rationale: Administering intravenous insulin is the initial priority in managing diabetic ketoacidosis (DKA). Insulin helps to reduce blood glucose levels and correct metabolic acidosis, addressing the underlying cause of DKA. Monitoring urine output (choice B) is important but is not the first intervention needed. Administering intravenous fluids (choice C) is essential to correct dehydration in DKA, but insulin therapy takes precedence. Administering 50% dextrose IV push (choice D) is contraindicated in DKA as it can exacerbate hyperglycemia.

4. A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement?

• A. Notify the healthcare provider.
• B. Review the client's medication history.
• C. Prepare the client for thyroid function tests.
• D. Initiate seizure precautions.

Correct answer: A

Rationale: In a scenario where a client with hyperthyroidism is not responding to medications, the nurse's priority action should be to notify the healthcare provider. This is important because the client may require immediate intervention, such as adjusting the treatment plan or exploring alternative therapies. Reviewing the client's medication history (choice B) may be relevant but not as urgent as involving the healthcare provider. While preparing the client for thyroid function tests (choice C) may be necessary as part of the evaluation process, it is not the most immediate action to take. Initiating seizure precautions (choice D) is not directly related to the non-responsiveness of medications in hyperthyroidism and is not a priority in this situation.

5. The nurse is caring for a client with end-stage renal disease (ESRD) who is scheduled for hemodialysis. Which clinical finding is most concerning?

• A. Blood pressure of 110/70 mmHg
• B. Heart rate of 110 beats per minute
• C. Fever of 100.4°F
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: The correct answer is C. A fever of 100.4°F is most concerning in a client with ESRD scheduled for hemodialysis because it may indicate an underlying infection that requires immediate attention. Elevated body temperature can be a sign of systemic infection, which can quickly worsen in individuals with compromised renal function. Monitoring for infection is crucial in ESRD patients to prevent complications. Choices A, B, and D are not as immediately concerning in this context. While variations in blood pressure, heart rate, and respiratory rate should be monitored, they are not as indicative of a potentially severe issue as an unexplained fever in this scenario.

Similar Questions