Nokea
A patient is experiencing shortness of breath. What is the nurse's immediate action?
- A. Assist the patient into a high Fowler's position.
- B. Administer oxygen at 2 liters per minute via nasal cannula.
- C. Encourage the patient to take deep breaths and cough.
- D. Assess the patient's lung sounds.
Correct Answer: B
Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.
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When teaching a patient about self-administration of insulin, what is the most important instruction to provide?
- A. Rotate injection sites to prevent tissue damage.
- B. Inject insulin at a 90-degree angle for proper absorption.
- C. Store insulin in the refrigerator to maintain potency.
- D. Teach the patient to administer insulin at the same time each day.
Correct Answer: A
Rationale: The most important instruction to provide when teaching a patient about self-administration of insulin is to rotate injection sites to prevent tissue damage. Rotating injection sites helps prevent lipodystrophy (tissue damage) and ensures proper insulin absorption. Option B is incorrect because the angle of insulin injection varies depending on the patient's body composition. Injecting at a 90-degree angle is not always necessary. Option C is not the most crucial instruction; while storing insulin in the refrigerator is important, it is not the priority when teaching self-administration. Option D is also important for maintaining consistency but is not as critical as rotating injection sites to prevent tissue damage.
Which of the following statements reflects the principles of sterile technique?
- A. Sterile objects that come in contact with unsterile objects are to be considered contaminated.
- B. Items in a sterile package must be used immediately once the package has been opened; otherwise, they are considered contaminated.
- C. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched.
- D. The edge of a sterile field and a border 1 inch (2.5 cm) inward is unsterile.
Correct Answer: A
Rationale: The correct statement reflecting the principles of sterile technique is that sterile objects that come in contact with unsterile objects are considered contaminated. This principle is crucial in maintaining asepsis during medical procedures. Choice B is incorrect because items in a sterile package should only be used if they remain sterile; opening the package does not automatically contaminate the items. Choice C is incorrect as any part of a sterile field that hangs below the top of the table is considered unsterile. Choice D is incorrect as the edge of a sterile field and a border inward are typically considered unsterile to maintain the integrity of the sterile area.
Which nursing action will most likely increase a patient's risk for developing a health care-associated infection?
- A. Uses a sterile bottled solution more than once within a 24-hour period.
- B. Uses surgical aseptic technique to suction an airway.
- C. Uses a clean technique for inserting a urinary catheter.
- D. Uses a cleaning stroke from the urinary meatus toward the rectum.
Correct Answer: C
Rationale: The correct answer is C. Using a clean technique for inserting a urinary catheter increases the risk for healthcare-associated infections. Invasive procedures like catheter insertion require a sterile technique to prevent introducing pathogens into the urinary tract. Choices A and B demonstrate appropriate infection control measures by emphasizing the use of sterile or aseptic techniques. Choice D represents an incorrect technique that can lead to the introduction of bacteria from the rectum into the urinary tract, potentially causing infections.
While providing care to a group of patients, which patient should the nurse see first?
- A. A patient after knee surgery who needs range of motion exercises
- B. A patient on bed rest who has renal calculi and needs to go to the bathroom
- C. A bedridden patient who has a reddened area on the buttocks who needs to be turned
- D. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
Correct Answer: D
Rationale: The nurse should see the patient with a hip replacement experiencing chest pain and dyspnea first because these symptoms could indicate a pulmonary embolism, which is a life-threatening condition requiring immediate attention. The other patients also need care, but urgent assessment and intervention are crucial in the case of potential pulmonary embolism to prevent serious complications or death.
The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next?
- A. Do not change the mask if the nurse is comfortable.
- B. Change the mask when relieved by the next shift.
- C. Apply a new mask.
- D. Reapply the mask after it air-dries.
Correct Answer: C
Rationale: When a surgical mask becomes moist, it loses its effectiveness as a barrier against microorganisms. Therefore, the perioperative nurse should apply a new mask. Choice A is incorrect because a moist mask should not be continued to be worn even if the nurse is comfortable. Choice B is not the best course of action as the mask should be changed immediately when it becomes moist. Choice D is also incorrect as waiting for the mask to air-dry is not recommended due to the loss of barrier effectiveness.