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A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?
- A. The nurse wears face protection, gloves, and a gown when irrigating a wound.
- B. The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled gloves.
- C. The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.
- D. The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.
Correct Answer: C
Rationale: The correct answer is C because putting on a second pair of gloves over soiled gloves during a procedure violates standard precautions by increasing contamination risk. Here's the rationale:
1. Standard precautions require removing soiled gloves before putting on new ones to prevent cross-contamination.
2. Wearing multiple gloves increases the risk of tearing and exposure to pathogens.
3. This behavior shows a lack of understanding of proper infection control practices.
Summary of other choices:
A: Wearing face protection, gloves, and a gown when irrigating a wound is a correct practice.
B: Washing hands with waterless antiseptic after removing soiled gloves is correct.
D: Placing a used needle and syringe in a puncture-resistant container without capping the needle is incorrect, but not as severe as choice C.
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A patient has been diagnosed with polycystic ovary syndrome (PCOS). The nurse should encourage what health promotion activity to address the patients hormone imbalance and infertility?
- A. Kegel exercises
- B. Increased fluid intake
- C. Weight loss
- D. Topical antibiotics as ordered
Correct Answer: C
Rationale: The correct answer is C: Weight loss. In PCOS, weight loss can help improve hormone balance and fertility by reducing insulin resistance and regulating hormone levels. Excess weight can exacerbate symptoms of PCOS. Kegel exercises (A) are beneficial for pelvic floor strength but do not directly address hormone imbalance. Increased fluid intake (B) is important for overall health but does not specifically target hormone imbalance. Topical antibiotics (D) are unrelated to PCOS treatment.
A smiling patient angrily states, “I will notcough and deep breathe.” How will the nurse interpret this finding?
- A. The patient’s denotative meaning is wrong.
- B. The patient’s personal space was violated.
- C. The patient’s affect is inappropriate.
- D. The patient’s vocabulary is poor.
Correct Answer: C
Rationale: The correct answer is C because the patient's affect, which refers to their emotional expression, is inappropriate. The patient is smiling while expressing anger, which is a contradiction. This inconsistency indicates a possible underlying issue such as emotional distress or confusion. Choice A is incorrect because the issue is not about the patient's understanding of the term "cough and deep breathe." Choice B is incorrect as there is no mention of personal space violation. Choice D is incorrect as the issue is not related to the patient's vocabulary but rather their emotional expression.
Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV?
- A. Gay, bisexual, and other men who have sex with men
- B. Recreational drug users
- C. Blood transfusion recipients
- D. Health care providers
Correct Answer: A
Rationale: The correct answer is A: Gay, bisexual, and other men who have sex with men. This group currently has the highest risk of contracting HIV due to various factors such as higher prevalence within this population, risky sexual behaviors, and limited access to healthcare services. Men who have sex with men have been disproportionately affected by HIV/AIDS since the beginning of the epidemic. Recreational drug users and blood transfusion recipients have lower overall risk compared to men who have sex with men. Health care providers, although at risk of occupational exposure, have lower risk compared to the other groups mentioned.
The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action isbestfor the nurseto take?
- A. Instill nonliquid medications without diluting.
- B. Irrigate the tube with 60 mL of water after all medications are given.
- C. Mix all medications together to decrease the number of administrations.
- D. Check with the pharmacy for availability of the liquid forms of medications.
Correct Answer: D
Rationale: Rationale for Correct Answer (D): Checking with the pharmacy for availability of liquid forms of medications is the best action because it reduces the risk of clogging the nasogastric tube. Liquid medications are less likely to cause blockages compared to nonliquid medications. Additionally, liquid forms are easier to administer through the tube. By using liquid medications, the nurse can ensure that the medications flow smoothly through the tube without causing any obstructions.
Summary of Incorrect Choices:
A: Instilling nonliquid medications without diluting can increase the risk of tube clogging.
B: Irrigating the tube with water after all medications are given may not prevent clogging effectively and could introduce unnecessary moisture into the tube.
C: Mixing all medications together can lead to potential drug interactions and may not address the issue of tube clogging effectively.
The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Hypercapnia
- D. Hypocapnia
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. The patient's symptoms like lethargy, thirst, headache, increased urination are indicative of high blood sugar levels. Lethargy is a common symptom of hyperglycemia due to the body's inability to use glucose effectively. Thirst and increased urination occur as the body tries to get rid of excess glucose through urine. Headache can result from dehydration due to increased urination. To address hyperglycemia, the nurse may need to adjust the patient's parenteral nutrition, monitor blood glucose levels, and potentially administer insulin.
Incorrect choices:
B: Hypoglycemia - Symptoms of hypoglycemia include sweating, confusion, and shakiness, which are not present in this case.
C: Hypercapnia - This is high carbon dioxide levels in the blood, typically caused by respiratory issues, not related to the symptoms described.
D: Hypocapnia - This is low carbon dioxide levels