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The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? Select all that apply.
- A. A sterile object is held below the table surface and returned to the sterile field.
- B. The outer inch of the sterile towel hangs over the side of the table.
- C. A partially emptied container of sterile betadine is replaced within the sterile field.
- D. Sterile packages are opened with the first edge away from the technician.
Correct Answer: A,B,C
Rationale: Holding a sterile object below the table surface, allowing the towel to hang over the edge, and replacing a partially used container all compromise sterility. Opening packages with the first edge away from the technician is correct technique.
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A nurse manager is educating a group of nursing students about the Patient's Bill of Rights. The nurse knows that the student nurses have an understanding of the bill when one of the nurses makes which statement?
- A. Clients have the right to view their medical records but may not copy any of the information contained in the records.
- B. Clients wavenumber be declined care at an emergency department or need preauthorization for care if they do not have premium-level insurance.
- C. Clients have the right to a quick and objective review of any claim that they levy against a health care facility, physician, or health care plan.
- D. It is the admitting nurse's job to verify the client's past medical history, medications, and treatments, even if the client refuses to cooperate in giving the information.
Correct Answer: C
Rationale: Clients have the right to a fair review of complaints, as per the Patient's Bill of Rights. The other options contain inaccuracies.
Nurses are expected to understand the principles of triage when caring for multiple clients. The ICU charge nurse is reviewing assignments. Based on the principles of triage, to which client would the charge nurse give priority for treatment? Select all that apply.
- A. a client on a ventilator who has an alarm sounding
- B. a client who has just returned from an open appendectomy
- C. a client ready to transfer to the floor after the nurse calls report
- D. a client who has been talking with family and is now unresponsive
- E. a client receiving a new antibiotic who complains of tingling in the mouth
Correct Answer: A,D,E
Rationale: A ventilator alarm, unresponsiveness, and tingling (possible anaphylaxis) indicate immediate threats to life, requiring priority in triage.
The charge nurse in the medical unit is preparing a bed assignment for a stable client diagnosed with necrotizing fasciitis. The client has a history of diabetes and hepatitis. There are four beds available. The nurse knows that the best roommate for this client is which of the following?
- A. a client with gout in the large toe
- B. a client with fever, vomiting, and diarrhea
- C. a client with MRSA
- D. a client with severe dementia with a tendency to wander
Correct Answer: A
Rationale: The gout client has a non-infectious condition, minimizing infection risk for the immunocompromised necrotizing fasciitis client.
The school nurse is monitoring the diet of a child with cystic fibrosis. Which type of diet would the family be advised to follow?
- A. low calorie, high fiber
- B. low fiber, low fat
- C. low sodium, gluten free
- D. high fat, high calorie
Correct Answer: D
Rationale: High-fat, high-calorie diets support nutritional needs in cystic fibrosis due to malabsorption.
The nurse is responsible for his own actions while on duty caring for clients. What is the name of this ethical principle? Fill in the blank.
- A. Accountability
Correct Answer: A
Rationale: Accountability is the ethical principle where nurses are responsible for their own actions and decisions in client care.