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In what order should the nurse perform the steps of a surgical hand scrub prior to entering the operating room?
- A. Rinse from the fingertips to the elbow
- B. Scrape under the nails with a nail pick
- C. Use a soapy brush to scrub the hands
- D. Cleanse the arm with a lathered brush
Correct Answer: B
Rationale: The correct order for performing a surgical hand scrub is to first scrape under the nails with a nail pick, then scrub the hands using a soapy brush, cleanse the arms, and finally rinse. This sequence ensures thorough cleaning and minimizes the risk of contamination. Choice A is incorrect because rinsing should be the final step, not the first. Choice C is incorrect as scrubbing the hands comes after scraping under the nails. Choice D is incorrect as cleansing the arms should follow hand scrubbing, not precede it.
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A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Pain scale rating of 9 on a 0-10 scale
- B. Last menstrual period was 7 weeks ago
- C. Reports white curdy vaginal discharge
- D. History of irritable bowel syndrome (IBS)
Correct Answer: B
Rationale: The correct answer is B. A missed menstrual period could indicate a possible pregnancy-related issue, requiring urgent evaluation. Assessing the menstrual history in a female of reproductive age takes precedence in this scenario. Choice A, the pain scale rating, is important but not as urgent as evaluating the menstrual history. Choice C, reporting white curdy vaginal discharge, may suggest a vaginal infection but is not as critical as ruling out a potential pregnancy. Choice D, the history of irritable bowel syndrome, is relevant but not as crucial as determining pregnancy-related issues in this context.
A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent urinary tract infection. What instruction should the nurse provide?
- A. Ensure to drink sugar-free cranberry juice
- B. Drinking cranberry juice does not prevent infection
- C. Cranberries do not affect insulin levels
- D. Excessive cranberry juice consumption can lead to constipation
Correct Answer: B
Rationale: The correct answer is B: Drinking cranberry juice does not prevent urinary tract infections and should not be relied upon as a preventive measure. While cranberry juice is often associated with preventing UTIs, there is limited scientific evidence to support this claim. Choice A is incorrect because the sugar content in cranberry juice is not the main concern when discussing its role in preventing UTIs. Choice C is incorrect as there is no significant evidence to suggest cranberries affecting insulin levels. Choice D is incorrect as constipation is not a typical side effect of consuming cranberry juice; however, excessive consumption may lead to gastrointestinal discomfort.
A male client admitted three days ago with respiratory failure is intubated and receiving 40% oxygen per facemask. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?
- A. Exhibits adequate tissue perfusion
- B. Remains free of injury
- C. Remains free of infection
- D. Maintains effective breathing pattern
Correct Answer: D
Rationale: Successful extubation is primarily measured by the client's ability to maintain an effective breathing pattern. This indicates that the client can adequately oxygenate and ventilate without the need for artificial airway support. Choices A, B, and C are important aspects of patient care but are not the primary outcomes to evaluate for successful extubation. Adequate tissue perfusion, freedom from injury, and prevention of infection are ongoing goals during the client's hospitalization but are not the immediate focus when considering extubation.
The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent, and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, 'She says it is OK.' What action should the nurse take next?
- A. Clarify the client's consent through the use of gestures and simple terms
- B. Have the interpreter co-sign the consent to validate the client's understanding
- C. Ask for a full explanation from the interpreter of the witnessed discussion
- D. Have the client sign the consent form and the nurse witness the signature
Correct Answer: B
Rationale: Having the interpreter co-sign the consent form is the most appropriate action in this scenario. By having the interpreter co-sign, it ensures an additional layer of verification of the client's understanding and consent, which is crucial when language barriers exist. This step adds a level of confirmation to safeguard that the client's consent is both valid and well-informed. Option A is not sufficient as gestures and simple terms may not fully clarify the client's understanding, especially for complex medical procedures. Option C is unnecessary since the interpreter has already confirmed the client's consent. Option D does not involve the interpreter in validating the client's understanding, which is essential in this situation to ensure effective communication and comprehension between the client and the healthcare team.
A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?
- A. Describe the safety of certain antianxiety medications during breastfeeding
- B. Encourage her to consider stress-relieving alternatives, such as deep breathing exercises
- C. Inform her that some antianxiety medications are safe to take while breastfeeding
- D. Explain that anxiety is a common response for the mother of a 3-week-old
Correct Answer: C
Rationale: The correct answer is C. Some antianxiety medications are considered safe for use while breastfeeding, and the nurse should provide this information to alleviate the woman's concerns. Choice A has been corrected to focus on the safety of certain antianxiety medications during breastfeeding, which is more accurate. Choice B suggests stress-relieving alternatives, which may help but do not address the need for antianxiety medication if required. Choice D is incorrect because it minimizes the woman's concerns by dismissing her increased anxiety as a normal response.