Nursing Elites

1. When preparing a sterile field for a procedure, which action should the nurse take to maintain sterility?

• A. Place sterile items around the sterile field
• B. Keep hands below waist level to avoid contamination
• C. Open the sterile package away from the body
• D. Avoid reaching over the sterile field

Correct answer: D

Rationale: To maintain sterility when preparing a sterile field, it is essential to avoid reaching over the sterile field. This action can introduce contaminants from the nurse's clothing or unsterile areas, compromising the sterility of the field. Placing sterile items around the sterile field (choice A) is incorrect as it may increase the risk of contamination by extending the area where non-sterile items may come in contact. Keeping hands below waist level (choice B) is also incorrect as it does not prevent contamination effectively. Opening the sterile package away from the body (choice C) is incorrect since it exposes the contents to the nurse's body, which is not sterile.

2. What intervention should the PN implement when taking the rectal temperature of an adult client?

• A. Lubricate the tip of the thermometer with a water-based gel.
• B. Gently insert the thermometer 1 inch into the rectum.
• C. Hold the thermometer in place the entire time while taking the temperature.
• D. Place the client in the left lateral position.

Correct answer: C

Rationale: When taking a rectal temperature, it is essential to hold the thermometer in place the entire time to ensure safety, accuracy, and prevent the thermometer from slipping out. Choice A, lubricating the tip of the thermometer with a water-based gel, is important for comfort and ease of insertion. Choice B, gently inserting the thermometer 1 inch into the rectum, is more accurate for adults than inserting it 3 inches. Choice D, placing the client in the left lateral position, is not necessary for a rectal temperature measurement.

3. What is the most effective way to communicate with a patient who has expressive aphasia?

• A. Asking yes or no questions
• B. Encouraging the patient to write responses
• C. Using picture boards or communication cards
• D. Speaking slowly and clearly

Correct answer: C

Rationale: The most effective way to communicate with a patient who has expressive aphasia is by using picture boards or communication cards. These tools allow patients to convey their needs and responses more effectively when they struggle to speak. Using picture boards or communication cards (Choice C) is preferred as it provides a visual aid to support communication. Asking yes or no questions (Choice A) may limit the patient's ability to express themselves fully. Encouraging the patient to write responses (Choice B) may not be suitable if the patient also has difficulty writing due to the aphasia. While speaking slowly and clearly (Choice D) is important, it may not be sufficient to overcome the communication challenges faced by patients with expressive aphasia.

4. A post-operative client develops a sudden onset of chest pain and dyspnea. The nurse suspects a pulmonary embolism (PE). What is the priority nursing action?

• A. Administer oxygen via face mask.
• B. Elevate the client's legs.
• C. Prepare the client for immediate surgery.
• D. Notify the healthcare provider immediately.

Correct answer: A

Rationale: Administering oxygen via face mask is the priority nursing action in a post-operative client suspected of a pulmonary embolism. This intervention helps ensure adequate oxygenation while further assessments and interventions are initiated. Elevating the client's legs is not indicated for a suspected pulmonary embolism; it is more appropriate for conditions like shock. Immediate surgery is not the priority in this situation as the client is experiencing acute symptoms requiring prompt intervention. While notifying the healthcare provider is important, the immediate focus should be on providing oxygen to the client to support respiratory function.

5. A client is recovering from a craniotomy and has a ventriculostomy in place. The nurse notices the drainage from the ventriculostomy is suddenly increasing. What should the nurse do first?

• A. Increase the head of the bed to 45 degrees.
• B. Clamp the ventriculostomy tube.
• C. Notify the healthcare provider immediately.
• D. Measure the client's head circumference.

Correct answer: C

Rationale: A sudden increase in drainage from a ventriculostomy could indicate a serious complication such as increased intracranial pressure or hemorrhage. The priority action in this situation is to notify the healthcare provider immediately to ensure prompt evaluation and intervention. Increasing the head of the bed may be beneficial in some situations but is not the first action to take. Clamping the ventriculostomy tube is inappropriate as it can lead to increased intracranial pressure. Measuring the client's head circumference is not the priority when there is a sudden increase in ventriculostomy drainage.

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