Nokea
The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up?
- A. Spills sterile water onto the sterile field
- B. Uses sterile gloves to handle sterile supplies on a sterile field
- C. Has sterile gauze placed into the sterile field
- D. Keeps the sterile field above their waist
Correct Answer: A
Rationale: Spilling sterile water contaminates the sterile field, requiring follow-up. Other actions are consistent with aseptic technique.
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The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
The nurse is caring for a client with pulmonary tuberculosis. Which action should the nurse take?
- A. Place a box of disposable respirators inside the client's room.
- B. Remove alcohol-based sanitizers from the client's room.
- C. Assign the client to a private room with a positive airflow.
- D. Remove the portable fan from the client's bedside table.
Correct Answer: D
Rationale: Removing the portable fan prevents the spread of airborne Mycobacterium tuberculosis. A negative airflow room is required, and respirators should be stored outside the room.
The nurse observes unlicensed assistive personnel (UAP) give a bed bath using 4% chlorhexidine (CHG) wipes. Which observation requires follow-up?
- A. The UAP uses one wipe for washing each major body part
- B. The UAP rinses the skin after bathing with the CHG solution
- C. The UAP washes the client's face with warm water and mild soap
- D. The UAP allows the CHG solution to dry on the client's skin
Correct Answer: B
Rationale: Rinsing CHG wipes removes their antimicrobial effect. Using separate wipes, washing the face separately, and allowing CHG to dry are correct.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with droplet precautions? Select all that apply.
- A. Clostridium difficile
- B. Cryptococcal meningitis
- C. Mycoplasma pneumonia
- D. Haemophilus influenzae, type b pneumonia
- E. Rheumatic fever
- F. Varicella Zoster
- G. Scabies
Correct Answer: C,D
Rationale: Mycoplasma pneumonia and Haemophilus influenzae pneumonia require droplet precautions. Others require contact or standard precautions.
The nurse observes a newly hired nurse apply bilateral soft-wrist restraints to a client. Which action by the newly hired nurse requires follow-up?
- A. Secures the restraint to the frame of the bed
- B. Repositions the client from semi-Fowler's to prone.
- C. Provides easy access to the quick release buckle
- D. Assesses the radial pulse every two hours
Correct Answer: B
Rationale: Positioning the client prone with wrist restraints is unsafe and increases risk of injury or respiratory compromise.