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The nurse is performing hand hygiene. Which actions should the nurse take when washing their hands with soap and water? Select all that apply.
- A. Use a paper towel to turn off the faucet.
- B. Keep the hands and forearms lower than the elbows during washing.
- C. Wash hands using hot water.
- D. Rinse the hands and wrists by keeping the hands down and elbows up.
- E. Wash hands for 5 to 10 seconds.
Correct Answer: A,B,D
Rationale: Using a paper towel, keeping hands lower, and rinsing correctly prevent contamination. Hot water is harsh, and washing should last 40-60 seconds.
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The nurse is preparing to remove an intrajugular central venous catheter. It would be appropriate to place the client in which position for this procedure?
- A. Reverse Trendelenburg
- B. Left lateral
- C. Trendelenburg
- D. High-Fowler's
Correct Answer: C
Rationale: Trendelenburg position (head down) reduces the risk of air embolism during intrajugular catheter removal by increasing venous pressure. Other positions do not minimize this risk effectively.
The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action?
- A. obtain a prescription for an antihypertensive
- B. determine if the client's pain is being controlled
- C. assess the client's surgical wound for signs of infection
- D. notify the physician for concerns of hypovolemic shock
Correct Answer: D
Rationale: Without specific clinical data, the priority for a client two days post-gastroduodenostomy is to assess for hypovolemic shock, a potential complication due to bleeding or fluid loss from the surgical site. This is more urgent than pain control, wound infection assessment, or antihypertensive needs, which require specific clinical indicators.
The nurse is performing an initial home health visit on a client who had a stroke one week ago with left-sided hemiparesis. Select the findings in the admission note that require follow-up.
- A. Affect was flat, and the client appeared withdrawn
- B. The client reported full adherence to their prescribed medications
- C. The client reported that they missed two physical therapy appointments.
- D. The client reported that they removed the cane's rubber tip because it left marks on their flooring.
- E. The client ambulated with the cane and held it in their right hand.
- F. The client advanced the cane 12-14 inches (30-36 cm) with each step
Correct Answer: A,C,D
Rationale: Flat affect, missed therapy, and removed rubber tip indicate depression, non-adherence, and safety risks, needing follow-up. Medication adherence, correct cane use, and proper advancement are appropriate.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with contact precautions? Select all that apply.
- A. Hepatitis C
- B. Cryptococcal meningitis
- C. Clostridium difficile
- D. Scabies
- E. Rheumatic fever
- F. Botulism
- G. Hepatitis B
Correct Answer: C,D
Rationale: Clostridium difficile and scabies require contact precautions due to direct or indirect transmission. Others require standard precautions.
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.