Nokea
A break in sterile technique occurs during surgery when the scrub nurse touches
- A. the mask with sterile gloved hands.
- B. sterile gloved hands to the gown at chest level.
- C. the drape at the incision site with sterile gloved hands.
- D. the lower arm to the instruments on the instrument tray.
Correct Answer: A
Rationale: Touching non-sterile items like masks compromises sterility and requires corrective action.
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The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Absence of fluid in the drainage tubing
- C. Continuous bubbling within the water seal chamber
- D. Equal amounts of fluid drainage in each collection chamber
Correct Answer: A
Rationale: The correct answer is A: Fluctuation of the fluid level within the water seal chamber. This indicates proper chest tube function as it shows that the system is maintaining the desired pressure and allowing for adequate drainage without obstruction. When the patient breathes in and out, the fluid level fluctuates due to changes in intrathoracic pressure.
Explanation of other choices:
B: Absence of fluid in the drainage tubing - This would indicate a problem with drainage, possibly due to a blockage in the tubing.
C: Continuous bubbling within the water seal chamber - This would suggest an air leak in the system, which is not ideal as it can lead to lung collapse.
D: Equal amounts of fluid drainage in each collection chamber - While equal drainage is good, it does not specifically indicate proper chest tube function like the fluctuation of the fluid level does.
In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents?
- A. Natural death acts
- B. Allow natural death
- C. Advance care planning
- D. Do Not Resuscitate order.
Correct Answer: C
Rationale: Advance care planning encompasses various legal documents that outline a person's healthcare preferences and appoints proxies to make decisions on their behalf when incapacitated.
What type of procedural information should be given to a patient in preparation for ambulatory surgery (select all that apply)?
- A. How pain will be controlled
- B. Any fluid and food restrictions
- C. Characteristics of monitoring equipment
- D. What odors and sensations may be experienced, Technique and practice of coughing and deep breathing, if appropriate
Correct Answer: D
Rationale: Providing comprehensive procedural information prepares the patient physically and mentally for surgery.
The nurse is reviewing the laboratory results for a preoperative patient. Which test result should be brought to the attention of the surgeon immediately?
- A. Serum K+ of 3.8 mEq/L
- B. Hemoglobin of 15 g/dL
- C. Blood glucose of 100 mg/dL
- D. White blood cell (WBC) count of 18,500/µL
Correct Answer: D
Rationale: An elevated WBC count indicates potential infection, requiring immediate attention.
A patient is scheduled for a hemorrhoidectomy at an ambulatory day-surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for
- A. laboratory tests and perioperative medications.
- B. preoperative and postoperative teaching by the nurse.
- C. psychologic support to alleviate fears of pain and discomfort.
- D. preoperative nursing assessment related to possible risks and complications.
Correct Answer: A
Rationale: Ambulatory centers often streamline processes, reducing the need for extensive laboratory tests and perioperative medications.