Nokea
Nurse wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.)
- A. Bottle containing sterile solution
- B. Edge of sterile drape at base of field
- C. Inner wrapping of an item on sterile field
- D. Irrigation syringe on sterile field
- E. One gloved hand with the other gloved hand
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: The nurse can touch the inner wrapping of an item on the sterile field because it is considered part of the sterile field and does not compromise the sterility.
D: The nurse can touch the irrigation syringe on the sterile field as it is within the sterile field and maintaining sterility.
E: The nurse can touch one gloved hand with the other gloved hand as long as both hands are sterile.
Summary:
A: Incorrect - Nurse should not touch a bottle containing sterile solution as it is not part of the sterile field.
B: Incorrect - Nurse should avoid touching the edge of a sterile drape at the base of the field as it is considered unsterile.
F & G: Not applicable.
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Nurse receives prescription for antibiotic for client with cellulitis. Nurse checks client's med record, discovers she's allergic to it, & calls provider to request different one. Which of following attitudes did the nurse demonstrate?
- A. fairness
- B. responsibility
- C. risk taking
- D. creativity
Correct Answer: B
Rationale: The correct answer is B: responsibility. The nurse demonstrated responsibility by ensuring patient safety and advocating for a suitable alternative antibiotic after discovering the allergy. This action aligns with the nurse's duty to provide safe and effective care.
Other choices are incorrect:
A: Fairness doesn't apply as the nurse's action was based on patient safety, not fairness.
C: Risk-taking is not demonstrated; the nurse acted based on known risks of the allergic reaction.
D: Creativity is not applicable here; the nurse followed standard protocols for managing allergies.
Nurse is receiving provider prescription by phone for morphine for client who is reporting moderate to severe pain. Which of the following actions are appropriate? (Select all that apply.)
- A. Repeat details of prescription back to provider
- B. Have another nurse listen to phone prescription
- C. Obtain prescriber’s signature on prescription within 24 hours
- D. Decline verbal prescription b/c it is not emergency situation
- E. Tell charge nurse that the provider has prescribed morphine by phone
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Repeating details back ensures accurate transcription and comprehension.
B: Having another nurse listen ensures a second verification of the prescription.
C: Obtaining the prescriber's signature within 24 hours ensures legal compliance and accountability.
Incorrect Choices:
D: Declining the prescription could delay pain relief for the client.
E: Informing the charge nurse alone does not ensure proper documentation and accountability.
Nurse preparing wellness presentation for families at community center. When discussing health screenings for adolescents, which info about scoliosis should nurse include?
- A. "scoliosis is more common in girls than in boys"
- B. loss of height is often first sign of scoliosis
- C. scoliosis screening is essential during adolescent growth spurt
- D. slouching is common cause of scoliosis, esp. in adolescents
- E. scoliosis is forward curvature of spine
Correct Answer: A, C
Rationale: Correct Answer: A, C
Rationale:
A: "Scoliosis is more common in girls than in boys" - Correct. Scoliosis is indeed more prevalent in girls, especially during adolescence.
C: "Scoliosis screening is essential during adolescent growth spurt" - Correct. Screening during growth spurts is crucial for early detection and intervention.
Summary:
B: Loss of height as the first sign of scoliosis is incorrect, as it is not a common symptom.
D: Slouching is not a cause of scoliosis; it is a misconception.
E: Scoliosis is a sideways curvature of the spine, not a forward curvature.
Nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should nurse manager include in teaching? (Select all that apply.)
- A. Request assistance when repositioning a client
- B. Avoid twisting spine or bending at waist
- C. Keep knees slightly lower than hips when sitting for long periods of time
- D. Use smooth movements when lifting & moving clients
- E. Take break from repetitive movements every 2-3h to flex & stretch joints & muscles
Correct Answer: A,B,D
Rationale: Correct Answer: A, B, D
Rationale:
A: Requesting assistance when repositioning a client is crucial to prevent injury as it reduces the risk of strain on the nurse's body.
B: Avoiding twisting the spine or bending at the waist helps in maintaining proper body mechanics and prevents back injuries.
D: Using smooth movements when lifting and moving clients reduces the risk of musculoskeletal injuries.
Summary of Incorrect Choices:
C: Keeping knees slightly lower than hips when sitting for long periods is related to ergonomics but not directly to preventing injury with client handling.
E: Taking breaks from repetitive movements every 2-3 hours is important for overall health but not specific to preventing injury with client handling.
Nurse is reviewing hand hygiene techniques with a group of APs. Which instructions should the nurse include when discussing handwashing? (Select all that apply.)
- A. Apply 3-5 mL of liquid soap to dry hands
- B. Wash hands with soap & water for at least 15 seconds
- C. Rinse hands with hot water
- D. Use a clean paper towel to turn off hand faucets
- E. Allow hands to air dry after washing
Correct Answer: B,D
Rationale: Correct Answer: B, D
Rationale:
B: Washing hands with soap & water for at least 15 seconds is crucial to ensure thorough cleaning and removal of germs.
D: Using a clean paper towel to turn off hand faucets helps prevent recontamination of clean hands.
Incorrect Choices:
A: Applying 3-5 mL of liquid soap to dry hands is not specified in handwashing guidelines.
C: Rinsing hands with hot water can strip the skin of natural oils and may not be necessary for effective hand hygiene.
E: Allowing hands to air dry after washing may not be sufficient to eliminate germs and is not a recommended step in hand hygiene protocols.