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A nurse is preparing to perform hand hygiene with an alcohol-based hand sanitizer. Which of the following actions should the nurse plan to take?
- A. Use hot water to rinse hand sanitizer off
- B. Dry hands with a reusable towel
- C. Rub hands together 20 seconds
- D. Rub hand sanitizer around rings on fingers
Correct Answer: D
Rationale: The correct answer is D: Rub hand sanitizer around rings on fingers. This is important because rings can harbor bacteria and viruses, and by rubbing hand sanitizer around them, the nurse ensures that all surfaces of the hands, including under the rings, are effectively sanitized. This action helps prevent the transmission of pathogens.
A: Using hot water to rinse hand sanitizer off is unnecessary and can actually be harmful as it can cause skin irritation.
B: Drying hands with a reusable towel is not recommended as it can harbor germs and compromise hand hygiene.
C: Rubbing hands together for 20 seconds is a good practice, but the specific action related to rings is more crucial.
E, F, G: No information provided.
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A nurse is admitting a new client. Which of the following steps of the nursing process is the nurse performing when formulating goals to address an identified problem?
- A. Planning
- B. Implementation
- C. Assessment
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Planning. In the nursing process, planning involves formulating goals and developing a plan of action to address the identified problems from the assessment phase. During this step, the nurse sets specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided. Planning ensures that interventions are tailored to the client's unique needs and helps achieve positive outcomes. The other choices are incorrect because: B: Implementation involves carrying out the plan, C: Assessment is the initial step of gathering data, and D: Evaluation is the final step to determine the effectiveness of the interventions.
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Increased blood pressure
- B. Increased hematocrit
- C. Increased respiratory rate
- D. Increased heart rate
- E. Increased temperature
Correct Answer: A,C,D
Rationale: The correct answer is A, C, and D. Fluid overload leads to increased blood pressure due to the increased volume of fluid in the vascular system. Increased respiratory rate occurs as the body tries to compensate for the excess fluid by increasing oxygen intake. Increased heart rate is a response to the increased workload on the heart to pump the excess fluid. Increased hematocrit and temperature are not typically associated with fluid overload. Hematocrit may actually be decreased due to hemodilution, and temperature is usually unaffected unless there is an underlying infection.
A nurse is caring for a client with a scheduled procedure. While preparing the client for transport they appear anxious and ask the nurse where they should hide their cellphone during the procedure. The nurse offers to lock the item in a secure area. Which category of Maslow's hierarchy of needs is the nurse addressing?
- A. Safety needs
- B. Esteem needs
- C. Love and belonging needs
- D. Physiological needs
Correct Answer: A
Rationale: The correct answer is A: Safety needs. At this moment, the nurse is addressing the client's need for safety by offering to secure their cellphone. Safety needs in Maslow's hierarchy refer to feeling secure, stable, and protected. By ensuring the client's belongings are safe, the nurse is addressing this fundamental need, which is crucial for the client's well-being during the procedure. Other choices are incorrect because: B: Esteem needs focus on self-respect and recognition from others, C: Love and belonging needs refer to relationships and social connections, and D: Physiological needs pertain to basic requirements like food and water, none of which are directly addressed in this scenario.
A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?
- A. Wait 10 sec after placing the probe before obtaining the oxygen saturation reading
- B. Place the sensor probe on the same extremity as an electronic blood pressure cuff
- C. Relocate the sensor every 8 hrs
- D. Choose a finger with a capillary refill less than 2 sec
Correct Answer: D
Rationale: The correct answer is D: Choose a finger with a capillary refill less than 2 sec. This is important because a capillary refill time longer than 2 seconds may indicate poor circulation, which can affect the accuracy of the oxygen saturation reading. It ensures proper blood flow to the finger, leading to a more reliable measurement. Waiting 10 seconds before obtaining the reading (A) is unnecessary and may delay timely intervention. Placing the sensor probe on the same extremity as an electronic blood pressure cuff (B) can interfere with accurate readings. Relocating the sensor every 8 hours (C) is not necessary for routine monitoring and may disrupt continuous monitoring.
A nurse is teaching a class about sleep disorders. The nurse should include that which of the following conditions can cause obstructive sleep apnea (OSA)?
- A. Heart failure
- B. Brainstem injury
- C. Recent weight loss
- D. Enlarged tonsils
Correct Answer: D
Rationale: The correct answer is D: Enlarged tonsils. Enlarged tonsils can physically obstruct the airway during sleep, leading to obstructive sleep apnea (OSA). This obstruction causes pauses in breathing during sleep, resulting in disrupted sleep patterns and decreased oxygen levels in the blood. Heart failure (A) is incorrect because it is not a direct cause of OSA. Brainstem injury (B) may disrupt the sleep-wake cycle but is not a common cause of OSA. Recent weight loss (C) can actually improve OSA symptoms by reducing the amount of tissue in the airway. Therefore, the most likely condition to cause OSA among the choices given is enlarged tonsils.