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During the surgical procedure, the nurse notices a break in sterile technique by a member of the surgical team. What should the nurse do?
- A. Document the break in sterile technique in the surgical log
- B. Continue with the procedure and address the issue later
- C. Inform the surgeon immediately and request corrective action
- D. Report the incident to the hospital's quality assurance department
Correct Answer: C
Rationale: In this situation, it is crucial for the nurse to inform the surgeon immediately and request corrective action. Maintaining a sterile field during surgical procedures is essential to prevent infections and ensure patient safety. Any break in sterile technique should be addressed promptly to prevent any potential harm to the patient. By informing the surgeon immediately, corrective action can be taken promptly to maintain the sterility of the surgical field and minimize the risk of complications. Reporting the incident to the surgeon also allows for immediate intervention and re-education of the team member involved in the break in sterile technique.
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A patient is exhibiting classic sign of a hemorrhagic stroke. What report from the patient would be an indicator of this type of stroke?
- A. Numbness of an arm or leg
- B. Severe headache
- C. Double vision
- D. Dizziness and tinnitus
Correct Answer: B
Rationale: A severe headache is a classic sign of a hemorrhagic stroke. Hemorrhagic stroke occurs when a blood vessel in the brain ruptures and causes bleeding. This bleeding can lead to increased pressure within the skull, resulting in a sudden and severe headache. Other symptoms of a hemorrhagic stroke may include nausea, vomiting, sudden weakness or numbness on one side of the body, difficulty speaking or understanding speech, and loss of coordination. It is important to seek immediate medical attention if someone is experiencing symptoms of a stroke, including a severe headache, as prompt treatment is crucial in minimizing damage and improving outcomes.
Which imaging modality is most commonly used to diagnose fractures of the long bones, such as the femur or tibia?
- A. X-ray
- B. Magnetic resonance imaging (MRI)
- C. Computed tomography (CT) scan
- D. Ultrasound
Correct Answer: A
Rationale: X-ray is the most commonly used imaging modality to diagnose fractures of the long bones, such as the femur or tibia. X-rays are readily available, fast, cost-effective, and provide detailed images of the bone structures. Fractures appear as breaks or discontinuities in the bone on X-ray images, making it an excellent tool for diagnosing bone fractures. In many cases, X-rays are sufficient to confirm the presence, location, and type of fracture, allowing for appropriate treatment planning. Other imaging modalities like MRI and CT scans may be used for further evaluation in complex cases, but X-ray remains the initial and primary choice for diagnosing long bone fractures.
Which of the following interventions is most appropriate for a patient with a tension pneumothorax?
- A. Needle decompression
- B. Chest tube insertion
- C. High-flow oxygen therapy
- D. Incentive spirometry
Correct Answer: A
Rationale: A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, causing increased pressure in the chest cavity. This can lead to compression of the lung and major blood vessels, leading to inadequate oxygenation and circulation.
Despite the short staffing, Nurse Cirila also has the responsibility to maintain safe environment for her pediatric patients. The following are the indicators that Nurse Cirila has achieved this goal, EXCEPT __________.
- A. Proper disposal of waste according to color coding
- B. Adherence to policies, protocols and procedures in the prevention and control of infection prevention.
- C. Assessing the competencies of a staff before delegating a task
- D. Observance of protocols in cases of earthquakes, fire and other emergencies.
Correct Answer: C
Rationale: The indicators listed indicate measures that Nurse Cirila can take to maintain a safe environment for her pediatric patients. However, assessing the competencies of staff before delegating a task is more related to ensuring effective delegation and appropriate task assignment rather than directly ensuring a safe environment for patients. While it is important to delegate tasks to qualified staff, this specific action does not directly contribute to maintaining a safe environment in the same manner as the other indicators listed (proper waste disposal, infection control, emergency protocols).
Transcription of doctor's order is a nurse's responsibility to put the order into action. Which of the following principles of medication safety is NOT considered to belong to transcription error?
- A. Illegible handwriting of the physician.
- B. Misinterpretation of the directions ordered.
- C. Use of unapproved abbreviation in the chart.
- D. Wrong route of medication administration.
Correct Answer: D
Rationale: Transcription errors are typically associated with issues such as illegible handwriting, misinterpretation of directions, and the use of unapproved abbreviations. However, the wrong route of medication administration is not specifically related to transcription errors but rather falls under the category of medication administration errors. Administering medication via the wrong route can lead to serious consequences for the patient and is a separate issue from the act of transcribing doctor's orders.