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During a sterile procedure at a client's bedside, a healthcare provider contaminates a sterile glove and the sterile field. What is the best action for the nurse to implement?
- A. Report the incident to the supervisor for aseptic technique violation.
- B. Allow the completion of the procedure.
- C. Inquire about the contamination of the glove and sterile field.
- D. Identify the breach in surgical asepsis and provide a new set of sterile supplies.
Correct Answer: D
Rationale: In the scenario where a healthcare provider contaminates a sterile glove and the sterile field during a procedure, it is crucial to identify any breach in surgical asepsis. Any potential contamination should be considered compromised, and the nurse must act promptly to maintain sterility by providing a fresh set of sterile supplies for the procedure to continue safely.
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An elderly patient has been living in a nursing home for several years. The nursing staff has begun to notice a change in her behavior. All of the following are symptoms of depression except:
- A. Changes in sleep patterns
- B. Changes in eating patterns with weight loss
- C. Excessive fatigue and increased concern with bodily functions
- D. Hyperorality
Correct Answer: D
Rationale: Hyperorality is not typically a symptom of depression. Symptoms of depression often include changes in sleep patterns, eating patterns with weight loss, and excessive fatigue. Hyperorality, which refers to the tendency to examine, chew, or ingest non-nutritive substances, is not a common symptom associated with depression.
A client is 2 days post-op from thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain as a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action?
- A. Instruct the client to use guided imagery and slow rhythmic breathing
- B. Provide at least 20 minutes of back massage and gentle effleurage
- C. Encourage the client to watch TV
- D. Place a hot water circulation device, such as an Aqua K pad, to the operative site
Correct Answer: A
Rationale: In this scenario, since no additional pain medication is available, the nurse should recommend non-pharmacological pain management techniques. Guided imagery and slow rhythmic breathing can help the client manage incisional pain effectively. These techniques can provide distraction and relaxation, potentially reducing the perception of pain without the need for additional medication.
The client is reviewing the signed operative consent with a nurse, who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement?
- A. Notify the surgical team of the client's confusion
- B. Have the client sign a new surgical consent
- C. Add the correct leg information to the consent form
- D. Inform the surgeon about the client's concern
Correct Answer: D
Rationale: In this scenario, the nurse should inform the surgeon about the client's concern immediately. This is important to ensure that the correct procedure is performed on the intended leg. Communication with the surgeon is crucial to address any discrepancies in the consent form and prevent errors during the surgical procedure. Having the surgeon clarify and correct the consent form is essential to maintain patient safety and uphold the principles of informed consent.
The client with cholecystitis is being instructed on dietary choices. Which meal best meets the dietary needs of this client?
- A. Steak, baked beans, and a salad
- B. Broiled fish, green beans, and an apple
- C. Pork chops, macaroni and cheese, and grapes
- D. Avocado salad, milk, and angel food cake
Correct Answer: B
Rationale: Cholecystitis requires a low-fat diet to reduce stress on the gallbladder. The meal of broiled fish, green beans, and an apple aligns with this dietary recommendation by providing lean protein and low-fat, high-fiber foods that are easier for the body to digest, making it the most suitable choice for a client with cholecystitis.
The nurse is preparing a client for surgery. What action is most important for the nurse to take?
- A. Ensure that the client signs the consent form.
- B. Review the client's allergies with the surgical team.
- C. Confirm the client's identity using two identifiers.
- D. Verify that the surgical site is marked.
Correct Answer: A
Rationale: Ensuring that the client signs the consent form (A) is the most crucial action before surgery. The consent form is legally and ethically necessary for the procedure to proceed. While reviewing allergies (B), confirming identity (C), and verifying the surgical site (D) are essential steps, obtaining the client's informed consent takes precedence to protect the client's rights and ensure a safe surgical experience.