Nursing Elites

1. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?

• A. Donning sterile gown and gloves to remove the wound dressing
• B. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
• C. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
• D. Donning clean goggles, gown, and gloves to dress the wound

Correct answer: C

Rationale: Choice C is the correct answer. When performing a sterile dressing change, it is essential to use clean gloves to remove soiled dressings and sterile gloves and supplies for applying the new dressing. This helps maintain aseptic technique and reduce the risk of introducing pathogens to the wound. Choices A, B, and D involve incorrect use of sterile and clean supplies, which can compromise the sterility of the procedure and increase the risk of infection.

2. A nurse is preparing to administer a blood transfusion. What is the most important action to ensure patient safety?

• A. Check the patient's vital signs every 15 minutes during the transfusion.
• B. Verify the patient's identity with two identifiers before starting the transfusion.
• C. Ensure the blood product is administered within 4 hours of removal from the blood bank.
• D. Ensure the patient has signed the informed consent form.

Correct answer: B

Rationale: The most important action to ensure patient safety when administering a blood transfusion is to verify the patient's identity with two identifiers before starting the transfusion. This step is crucial to prevent transfusion errors, such as giving the blood to the wrong patient. Checking vital signs, ensuring timely administration, and confirming informed consent are also important aspects of blood transfusion safety but verifying the patient's identity is the highest priority to prevent errors.

3. A client has a prescription for vancomycin 1g IV intermittent infusion over 30 minutes every 12 hours. What action should the nurse take?

• A. Start the infusion immediately
• B. Slow down the infusion rate
• C. Contact the provider for prescription clarification
• D. Check blood pressure during the infusion

Correct answer: C

Rationale: The correct action for the nurse to take is to contact the provider for prescription clarification. Administering vancomycin over less than 60 minutes can lead to infusion reactions like hypotension and flushing. Starting the infusion immediately (choice A) is incorrect as it goes against the prescribed rate. Slowing down the infusion rate (choice B) without provider approval can result in underdosing the medication. Checking blood pressure during the infusion (choice D) is important but not the most immediate action needed in this situation.

4. What is a key characteristic of Illness Anxiety Disorder?

• A. Excessive focus on minor symptoms without medical evidence of illness
• B. The need for consistent reassurance from healthcare professionals
• C. Compulsive behavior to avoid physical illness
• D. Development of avoidance behaviors to reduce anxiety

Correct answer: A

Rationale: The correct answer is A: "Excessive focus on minor symptoms without medical evidence of illness." Illness Anxiety Disorder, formerly known as hypochondriasis, is characterized by a preoccupation with having a serious illness despite no medical evidence to support the presence of an illness. Individuals with this disorder often interpret normal bodily sensations as signs of severe illness. Choice B is incorrect because while individuals with Illness Anxiety Disorder may seek reassurance from healthcare professionals, the excessive focus on minor symptoms is the key characteristic. Choice C is incorrect as compulsive behaviors to avoid physical illness are more characteristic of illnesses like Obsessive-Compulsive Disorder. Choice D is incorrect as the development of avoidance behaviors to reduce anxiety is more commonly seen in conditions like specific phobias or social anxiety disorder.

5. If a client refuses surgery, but the family insists, what should the nurse do in this situation?

• A. Respect the family's decision and proceed with the surgery.
• B. Respect the client's decision and notify the healthcare provider.
• C. Try to mediate between the family and the client.
• D. Encourage the client to follow their family's wishes.

Correct answer: B

Rationale: In this situation, the nurse should respect the client's decision and notify the healthcare provider. The client has the right to refuse treatment, and the nurse must advocate for the client's autonomy. Proceeding with the surgery against the client's wishes would violate their autonomy and ethical principles. Trying to mediate between the family and the client may be appropriate, but ultimately, the client's decision should be respected. Encouraging the client to follow their family's wishes disregards the client's autonomy and is not ethically appropriate.

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