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A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
- A. The nurse washes with her hands held higher than her elbows.
- B. The nurse uses an alcohol-based hand rub for 30 seconds.
- C. The nurse scrubs hands and forearms for 2 minutes with soap and water.
- D. The nurse washes her hands with soap and water for only 15 seconds.
Correct Answer: A
Rationale: Proper surgical hand-washing technique involves washing with the hands held higher than the elbows. This positioning is essential to ensure proper rinsing and to prevent the risk of contamination. Option B, using an alcohol-based hand rub for 30 seconds, is not specific to surgical hand-washing and is more commonly used for routine hand hygiene. Option C, scrubbing hands and forearms for 2 minutes with soap and water, is excessive and not typically required for routine hand-washing. Option D, washing hands with soap and water for only 15 seconds, is insufficient for thorough surgical hand-washing.
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A client with chronic kidney disease is being assessed. Which of the following laboratory values would be most concerning?
- A. Serum creatinine of 3.0 mg/dL
- B. Serum potassium of 6.5 mEq/L
- C. Blood urea nitrogen (BUN) of 45 mg/dL
- D. Hemoglobin of 10 g/dL
Correct Answer: B
Rationale: In a client with chronic kidney disease, elevated serum potassium levels (hyperkalemia) are the most concerning finding. Hyperkalemia can lead to life-threatening cardiac dysrhythmias. Monitoring and managing serum potassium levels are crucial in patients with kidney disease to prevent severe complications. While elevated creatinine (Choice A) and BUN (Choice C) are indicative of impaired kidney function, hyperkalemia poses a more immediate threat to the client's health. Hemoglobin levels (Choice D) can be affected by chronic kidney disease but are not as acutely dangerous as severe hyperkalemia.
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
- A. Protective environment
- B. Airborne precautions
- C. Droplet precautions
- D. Contact precautions
Correct Answer: D
Rationale: The correct answer is D: Contact precautions. When a client has an abdominal wound with purulent drainage, contact precautions are necessary to prevent the spread of infection through direct contact. Protective environment precautions are used for immunocompromised clients, airborne precautions are for diseases transmitted by airborne particles, and droplet precautions are for diseases transmitted by respiratory droplets. In this case, the focus is on preventing direct contact transmission, making contact precautions the most appropriate choice. Protective environment, airborne, and droplet precautions are not indicated in this scenario because the primary concern is the direct contact transmission of pathogens through the wound drainage.
When a client files a lawsuit against an LPN for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as:
- A. Evidence
- B. Tort discovery
- C. Proximate cause
- D. Common cause
Correct Answer: C
Rationale: The correct answer is C, 'Proximate cause.' Proximate cause establishes the link between the harm suffered and the negligent actions performed by the nurse. In a malpractice lawsuit, proving proximate cause is essential to demonstrate that the nurse's actions directly led to the harm experienced by the client. Choice A, 'Evidence,' is incorrect as evidence is the information presented to support or refute a claim, not specifically the link between harm and negligence. Choice B, 'Tort discovery,' is incorrect as it does not specifically refer to establishing the link between harm and negligence. Choice D, 'Common cause,' is incorrect as it does not capture the legal concept of proximate cause in establishing liability in malpractice cases.
When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?
- A. Bleeding time
- B. Coagulation time
- C. Prothrombin time
- D. Partial thromboplastin time
Correct Answer: C
Rationale: The correct answer is C: Prothrombin time (PT). Prothrombin time is monitored to assess the therapeutic response to warfarin therapy. Warfarin works by inhibiting vitamin K-dependent clotting factors, which prolongs the PT. Monitoring PT helps determine if the client's blood is clotting within the desired therapeutic range. Choices A, B, and D are incorrect because bleeding time, coagulation time, and partial thromboplastin time are not specifically used to monitor the therapeutic response to warfarin. Bleeding time assesses platelet function, coagulation time is a general term and not a specific test, and partial thromboplastin time is more relevant in monitoring heparin therapy, not warfarin.
A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?
- A. Notify the nursing manager.
- B. Document the client's condition and communication with the surgeon.
- C. Administer additional fluids as per standard procedure.
- D. Call the surgeon back immediately to ensure timely intervention.
Correct Answer: B
Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.