Nursing Elites

1. Which nursing action will most likely increase a patient's risk for developing a health care-associated infection?

• A. Uses a sterile bottled solution more than once within a 24-hour period.
• B. Uses surgical aseptic technique to suction an airway.
• C. Uses a clean technique for inserting a urinary catheter.
• D. Uses a cleaning stroke from the urinary meatus toward the rectum.

Correct answer: C

Rationale: The correct answer is C. Using a clean technique for inserting a urinary catheter increases the risk for healthcare-associated infections. Invasive procedures like catheter insertion require a sterile technique to prevent introducing pathogens into the urinary tract. Choices A and B demonstrate appropriate infection control measures by emphasizing the use of sterile or aseptic techniques. Choice D represents an incorrect technique that can lead to the introduction of bacteria from the rectum into the urinary tract, potentially causing infections.

2. Which of the following actions is a means of maintaining medical asepsis to reduce and prevent the spread of microorganisms?

• A. Sterilizing contaminated items
• B. Routinely cleaning the hospital environment
• C. Reapplying a sterile dressing
• D. Applying a sterile gown and gloves

Correct answer: A

Rationale: The correct answer is A: Sterilizing contaminated items. Maintaining medical asepsis involves ensuring that items are free of microorganisms to prevent infections. Sterilizing contaminated items is a crucial step in this process as it eliminates all microorganisms, including spores. Choices B, C, and D do not directly address the process of reducing and preventing the spread of microorganisms. While routinely cleaning the hospital environment is important for cleanliness, it does not guarantee the elimination of all microorganisms. Reapplying a sterile dressing and applying a sterile gown and gloves are specific actions related to personal protective equipment and wound care, not the general maintenance of medical asepsis.

3. A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

• A. Increased heart rate
• B. Decreased temperature
• C. Serosanguineous drainage from the puncture site
• D. Discomfort at the puncture site

Correct answer: A

Rationale: Correct Answer: A nurse should identify an increased heart rate as a complication following a thoracentesis and contact the provider immediately. An increased heart rate may indicate a pneumothorax or other serious complications. Choices B, C, and D are incorrect because decreased temperature, serosanguineous drainage, and discomfort at the puncture site are expected findings following a thoracentesis and do not indicate a significant complication requiring immediate provider notification.

4. A patient with a left arm fracture reports severe pain unrelieved by medication. What should the nurse assess for?

• A. Check for compartment syndrome
• B. Increase the pain medication
• C. Prepare the patient for surgery immediately
• D. Administer a sedative to calm the patient

Correct answer: A

Rationale: Correct answer: When a patient with a left arm fracture reports severe pain unrelieved by medication, the nurse should assess for compartment syndrome. Compartment syndrome is a condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. It is a surgical emergency that requires immediate intervention. Choice B is incorrect because simply increasing pain medication without identifying the cause of the unrelieved pain may mask symptoms of a serious issue like compartment syndrome. Choice C is incorrect as surgery would only be necessary if compartment syndrome is confirmed. Choice D is incorrect as administering a sedative does not address the underlying issue of unrelieved pain and may delay appropriate treatment.

5. A patient is on contact precautions for an infection. What is the most important action for the nurse to take?

• A. Wear gloves when entering the patient's room.
• B. Place the patient in a private room.
• C. Use a dedicated blood pressure cuff for the patient.
• D. Dispose of all equipment in a biohazard bag.

Correct answer: A

Rationale: The most important action for the nurse to take when caring for a patient on contact precautions is to wear gloves when entering the patient's room. This is crucial in preventing the spread of infection from the patient to the healthcare provider and vice versa. Placing the patient in a private room may be necessary for airborne precautions but is not specifically related to contact precautions. Using a dedicated blood pressure cuff for the patient is important for preventing cross-contamination but is not the most critical action. Disposing of equipment in a biohazard bag is a standard procedure but is not the most important action in this scenario.

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