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A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse breaks in surgical aseptic technique?
- A. Balancing the bottle on the sterile basin while pouring the liquid
- B. Clarify the reason for the referral
- C. Identify family needs and interventions
- D. Provide discharge teaching
Correct Answer: A
Rationale: The correct answer is A because balancing the bottle on the sterile basin contaminates the sterile field. Sterile technique requires keeping all items above waist level, avoiding leaning over the sterile field, and maintaining a safe distance to prevent contamination. Choices B, C, and D are unrelated to sterile technique and do not involve direct contact with the sterile field. Clarifying the reason for referral, identifying family needs, and providing discharge teaching are important aspects of nursing care but do not pertain to maintaining a sterile field during wound irrigation and dressing change.
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The nurse is discussing the importance of evidence-based decision-making (EBDM) with a group of students. Which statement by a student indicates understanding of this process?
- A. "EBDM is a one-step process to make clinical decisions.â€
- B. "EBDM utilizes subjective decision-making.â€
- C. "EBDM uses interventions with replicable results.â€
- D. "EBDM relies on past nursing experiences.â€
Correct Answer: C
Rationale: The correct answer is C: "EBDM uses interventions with replicable results." This statement indicates an understanding of evidence-based decision-making (EBDM) because it highlights the key principle of using interventions that have been proven to produce consistent and replicable results through research and evidence. By basing decisions on interventions with replicable results, healthcare professionals can ensure that their clinical decisions are informed by reliable evidence rather than personal bias or subjective opinions.
Choice A is incorrect because EBDM is a multi-step process that involves gathering evidence, critically appraising it, and applying it to make decisions. Choice B is incorrect as EBDM focuses on objective evidence rather than subjective decision-making. Choice D is incorrect because while past nursing experiences may inform decision-making, EBDM emphasizes the use of current research and evidence to guide practice.
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
- A. Your desire to be an organ donor must be documented in writing
- B. Performing a physical examination of an ill client
- C. Providing treatment and health education to a client with a disease
- D. Giving some of their own surplus clothes to those who can use them
Correct Answer: A
Rationale: The correct answer is A because organ donation requires documented consent to ensure the individual's wishes are respected. This documentation is crucial for legal and ethical reasons. Choice B is incorrect as it pertains to conducting a physical examination, not related to organ donation. Choice C focuses on treatment and health education, not addressing the client's inquiry about organ donation. Choice D involves donating clothes, which is unrelated to organ donation. Therefore, A is the correct response as it addresses the client's query about organ donation by emphasizing the need for written documentation.
The nurse has been reading extensively on a particular clinical problem, using both the closest medical library and the Internet. Which of the following would be the most helpful source?
- A. A journal with a whole issue devoted to research on that clinical problem
- B. A randomized controlled clinical trial related to that clinical problem
- C. A researcher who has built a career on studying that clinical problem
- D. A systematic review related to the clinical problem
Correct Answer: D
Rationale: The correct answer is D: A systematic review related to the clinical problem. This is because a systematic review provides a comprehensive summary of all available evidence on a specific topic, including individual studies such as randomized controlled trials. It helps to synthesize and critically appraise the existing research, offering a high level of evidence to guide clinical practice. Choice A may provide in-depth research but may not cover all relevant studies. Choice B is a single study and may not offer a broad perspective. Choice C focuses on a single researcher and may not encompass the full spectrum of evidence.
A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis. Which of the following assessments should the nurse perform as part of this screening?
- A. Measure the truncal rotation
- B. Administered 8 u regular insulin sq
- C. Determine if the stockings are binding
- D. Arrange for an ethics committee meeting
Correct Answer: A
Rationale: The correct answer is A: Measure the truncal rotation. When screening for idiopathic scoliosis, assessing truncal rotation is essential as it helps in detecting the presence of spinal curvature. Truncal rotation is a key indicator of scoliosis as the spine rotates along with the curvature. This assessment involves observing the symmetry of the shoulders and scapulae, which can indicate spinal rotation. Therefore, measuring truncal rotation is a crucial step in identifying potential scoliosis in adolescents.
Summary:
B: Administered 8 u regular insulin sq - Irrelevant to scoliosis screening, this is related to diabetes management.
C: Determine if the stockings are binding - Irrelevant to scoliosis screening, this is related to circulation issues.
D: Arrange for an ethics committee meeting - Irrelevant to scoliosis screening, this is related to ethical considerations in healthcare.
Which environmental health activity would the nurse perform while engaged in the core public health function of assurance?
- A. Educating the community about the need to boil contaminated drinking water
- B. Collecting data about health issues related to contaminated drinking water
- C. Developing polices to regulate the discharge of pollutants into the waterways
- D. Assessing measures to reduce exposure to contaminated water
Correct Answer: D
Rationale: The correct answer is D: Assessing measures to reduce exposure to contaminated water. This activity falls under the assurance function as it involves ensuring that appropriate measures are in place to protect the community from health risks associated with contaminated water. By assessing these measures, the nurse is actively working to reduce the community's exposure to harmful contaminants, thereby fulfilling the role of assuring the public's health.
A: Educating the community about the need to boil contaminated drinking water falls under the core function of education rather than assurance.
B: Collecting data about health issues related to contaminated drinking water is a part of the assessment function, not assurance.
C: Developing policies to regulate the discharge of pollutants into the waterways is more aligned with the policy development function rather than assurance.
In summary, the correct answer focuses on actively evaluating and implementing measures to reduce exposure to contaminated water, which directly contributes to the assurance function of environmental health.