Nokea
Nurse wearing sterile gloves in prep for performing sterile procedure. Which of following objects may nurse touch without breaching sterile technique?
- A. Bottle containing sterile solution
- B. Edge of sterile drape at base of field
- C. Inner wrapping of an item on sterile field
- D. Irrigation syringe on sterile field
- E. 1 gloved hand with the other gloved hand
Correct Answer: C,D,E
Rationale: The correct choices are C, D, and E. The nurse can touch the inner wrapping of an item on the sterile field because it is considered sterile. The nurse can touch the irrigation syringe on the sterile field as long as it is also considered sterile and part of the field. The nurse can also touch one gloved hand with the other gloved hand, as the gloves are considered sterile. Choices A and B are incorrect because touching the bottle or the edge of the drape would breach sterile technique.
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Occupational health nurse is caring for employee with chemical burn from unknown chemical. Which intervention should nurse include in care plan?
- A. Irrigate affected area with running water
- B. Wash affected area with antibacterial soap
- C. Brush chemical off skin & clothing
- D. Apply neutralizing agent
Correct Answer: C
Rationale: The correct answer is C: Brush chemical off skin & clothing. This intervention is crucial because removing the chemical from the skin and clothing helps prevent further exposure and damage. Irrigating the affected area with running water (choice A) may spread the chemical and worsen the burn. Washing with antibacterial soap (choice B) is not recommended for chemical burns. Applying a neutralizing agent (choice D) can be harmful if the chemical is unknown. The key is to remove the chemical by brushing it off to minimize skin contact and reduce the risk of absorption.
Nurse is reviewing hand hygiene techniques with group of AP, which instructions should nurse include when discussing handwashing?
- A. Apply 3-5 mL of liquid soap to dry hands
- B. Wash hands with soap & water for at least 15 seconds
- C. Rinse hands with hot water
- D. Use clean paper towel to turn off hand faucets
- E. Allow hands to air dry after washing
Correct Answer: B,D
Rationale: The correct answers are B and D. Option B instructs to wash hands with soap and water for at least 15 seconds, which is recommended by CDC for thorough handwashing. Option D advises using a clean paper towel to turn off hand faucets to avoid recontaminating hands after washing. This is crucial to prevent the spread of germs.
Explanation for other choices:
A: Applying 3-5 mL of liquid soap to dry hands is not mentioned in hand hygiene guidelines.
C: Rinsing hands with hot water is not necessary and can actually be harmful to the skin.
E: Allowing hands to air dry is acceptable, but it is not a crucial instruction for handwashing.
Nurse is planning diversionary activities for children on inpatient peds unit. Which should nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.)
- A. Assembling puzzles
- B. Pulling wheeled toys
- C. Using musical toys
- D. Using finger paints
- E. Coloring with crayons
Correct Answer: A,C,E
Rationale: The correct activities for preschoolers are A, C, and E. A: Assembling puzzles promotes problem-solving and fine motor skills. C: Using musical toys enhances auditory skills and creativity. E: Coloring with crayons supports fine motor skills and creativity. B: Pulling wheeled toys may not be safe or developmentally appropriate. D: Using finger paints can be messy and may not be suitable for all children, especially those with sensory sensitivities.
The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? Select all that apply
- A. Close all doors.
- B. Note evacuation routes.
- C. Note oxygen shut-offs.
- D. Move bedridden patients in their bed.
- E. Wait until the fire department arrives to act.
- F. Use type B fire extinguishers for electrical fires.
Correct Answer: A, B, C, D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Close all doors - By closing doors, the nurse can prevent the spread of smoke and fire, protecting patients.
B: Note evacuation routes - Knowing evacuation routes ensures a safe and efficient evacuation if needed.
C: Note oxygen shut-offs - Turning off oxygen can reduce the risk of fire spreading and explosions.
D: Move bedridden patients in their bed - Moving bedridden patients quickly and safely is crucial for their well-being during an emergency.
Summary:
E: Waiting for the fire department is not proactive and can waste valuable time in ensuring patient safety.
F: Using type B fire extinguishers for electrical fires is incorrect as type C extinguishers are recommended for electrical fires.
G: There is no information provided for this option.
A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel?
- A. Determining the level of comfort
- B. Changing the patient's position
- C. Identifying immobility hazards
- D. Assessing circulation
Correct Answer: B
Rationale: The correct answer is B: Changing the patient's position. This task can be delegated to nursing assistive personnel as it involves physically moving the patient, which does not require advanced nursing knowledge or assessment skills. Nursing assistive personnel are trained to safely reposition patients under the supervision of a nurse. Choices A, C, and D involve critical thinking, assessment, and decision-making skills that require a nurse's expertise, so they cannot be delegated.