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Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?
- A. Circle the surgical site with a marker.
- B. Verify patient information with a designated patient representative.
- C. Designate operative site with a facility designated mark.
- D. Include a copy of the Advanced Directives on the chart before surgery.
- E. Verify patient information three times.
- F. Observe pre-op time out before proceeding with surgery.
Correct Answer: C, E, F
Rationale: Joint Commission protocols include marking the site with a facility-designated mark (C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (A) is not standard. Patient representative verification (B) and advance directives (D) are not part of site verification.
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A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
- A. Keep breathing with your abdominal muscles as long as you can.
- B. Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16-20 times a minute with shallow chest breaths.
- C. Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.
- D. If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well.
Correct Answer: B
Rationale: Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. It is important to assume a comfortable position in labor, but the Lamaze-prepared laboring woman is taught to breathe with her chest, not abdominal, muscles. When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6-9 breaths/min.
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse knows that RhoGam is given at:
- A. One finger breadth below the umbilicus
- B. The deltoid
- C. Two finger breadths above the trochanter
- D. Two finger breadths below the umbilicus
Correct Answer: B
Rationale: RhoGam is administered intramuscularly, typically in the deltoid muscle, for Rh-negative mothers to prevent sensitization. The other locations are incorrect for IM injections of RhoGam.
The client is diagnosed with a urinary tract infection. Which instruction should the nurse include in the discharge teaching?
- A. Limit fluid intake to reduce bladder irritation.'
- B. Take all prescribed antibiotics as directed.'
- C. Avoid sexual activity permanently.'
- D. Use heating pads to relieve discomfort.'
Correct Answer: B
Rationale: Completing the full course of antibiotics is essential to eradicate the infection and prevent resistance in a urinary tract infection. Fluid intake should increase, sexual activity can resume after treatment, and heating pads may not be advised.
The client is admitted with a diagnosis of acute respiratory distress syndrome (ARDS). Which intervention should the nurse anticipate?
- A. Mechanical ventilation
- B. Nebulizer treatments
- C. Chest physiotherapy
- D. Antibiotic therapy
Correct Answer: A
Rationale: ARDS causes severe hypoxemia, often requiring mechanical ventilation to maintain oxygenation. Nebulizers, physiotherapy, and antibiotics are secondary or condition-specific.
A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?
- A. Cullen's sign
- B. Rebound tenderness
- C. Murphy's sign
- D. Turner's sign
Correct Answer: C
Rationale: This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.