Nokea
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.
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The nurse is conducting an in-service for nursing students. It would be appropriate for the nurse to state which of the following procedures requires a sterile technique? Select all that apply.
- A. Changing the dressing for a central line
- B. Inserting an indwelling urinary catheter
- C. Removing a peripheral vascular access device
- D. Suctioning an endotracheal tube with in-line suction
- E. Inserting a nasogastric tube (NGT)
Correct Answer: A,B,D
Rationale: Sterile technique is required for central line dressing changes, indwelling urinary catheter insertion, and endotracheal suctioning due to the risk of introducing pathogens into sterile areas.
The nurse is caring for a client with a tracheostomy who requires suctioning. Which of the following actions by the nurse would indicate correct technique?
- A. Using a size 16 Fr catheter to suction the client.
- B. Withdrawing the suction catheter 1 to 2 cm before applying suction.
- C. Using 160 mm Hg of pressure when suctioning the client.
- D. Applying suction to the catheter for 25 seconds during withdrawal.
Correct Answer: B
Rationale: Withdrawing the catheter 1-2 cm before suctioning prevents mucosal trauma. A 16 Fr catheter may be too large, 160 mm Hg is excessive (80-120 mm Hg is typical), and suctioning for 25 seconds is too long (≤10-15 seconds).
Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic?
- A. Autologous donations require a health care provider's (HCP) order
- B. There is no age limitation for autologous blood donations
- C. I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery
- D. My autologous blood donation will be screened for infectious diseases
Correct Answer: B
Rationale: There are age limitations for autologous blood donations, typically excluding very young or elderly patients due to health risks. The other statements are correct: a provider’s order is required, donations can start five weeks and stop 72 hours before surgery, and blood is screened for infectious diseases.
The nurse is caring for an older adult following a total hip arthroplasty. The nurse should anticipate a prescription for which postoperative medication?
- A. Hydrocortisone
- B. Enoxaparin
- C. Metoprolol
- D. Furosemide
- E. Morphine
Correct Answer: B,E
Rationale: Enoxaparin prevents venous thromboembolism, a common risk post-hip arthroplasty, and morphine manages postoperative pain. Hydrocortisone, metoprolol, and furosemide are not routinely prescribed unless indicated by specific conditions.
The nurse is conducting a staff conference regarding standard precautions. It would be correct for the nurse to state that hand washing with soap and water is required when
- A. Hands are visibly soiled.
- B. Collecting vital signs (VS).
- C. Performing range of motion exercises.
- D. Inputting data into the electronic medical record (EMR).
Correct Answer: A
Rationale: Soap and water are required for visibly soiled hands, as alcohol-based rubs are less effective. Other activities can use hand rubs unless soiled.