Nokea
Which of the following statements reflects the principles of sterile technique?
- A. Sterile objects that come in contact with unsterile objects are to be considered contaminated.
- B. Items in a sterile package must be used immediately once the package has been opened; otherwise, they are considered contaminated.
- C. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched.
- D. The edge of a sterile field and a border 1 inch (2.5 cm) inward is unsterile.
Correct Answer: A
Rationale: The correct statement reflecting the principles of sterile technique is that sterile objects that come in contact with unsterile objects are considered contaminated. This principle is crucial in maintaining asepsis during medical procedures. Choice B is incorrect because items in a sterile package should only be used if they remain sterile; opening the package does not automatically contaminate the items. Choice C is incorrect as any part of a sterile field that hangs below the top of the table is considered unsterile. Choice D is incorrect as the edge of a sterile field and a border inward are typically considered unsterile to maintain the integrity of the sterile area.
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A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?
- A. Encourage visitors during visiting hours.
- B. Keep the patient on fall precautions until discharge.
- C. Check on the patient every shift.
- D. Raise all four side rails.
Correct Answer: B
Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.
A patient with diabetes is admitted with high blood sugar levels. What is the nurse's priority intervention?
- A. Administer insulin as prescribed.
- B. Encourage the patient to exercise regularly.
- C. Encourage the patient to drink water.
- D. Provide the patient with a low-sugar diet.
Correct Answer: A
Rationale: Administering insulin is the priority intervention for a patient admitted with high blood sugar levels because it helps lower the blood sugar levels effectively and rapidly. Insulin is a crucial medication for managing hyperglycemia in diabetes. Encouraging exercise (choice B) can be beneficial in the long term for managing blood sugar levels but is not the most immediate priority. While staying hydrated (choice C) is important, it is not the priority intervention when dealing with high blood sugar levels. Providing a low-sugar diet (choice D) is essential for long-term diabetes management but is not the immediate action needed to address high blood sugar levels in an admitted patient.
A nurse manager assigns a nursing assistant a task outside of their role. What should the nursing assistant do?
- A. Follow the manager's directive
- B. Report the task to the charge nurse
- C. Refuse to perform the task
- D. Perform the task and document later
Correct Answer: B
Rationale: If a nurse manager assigns a nursing assistant a task that is outside of their role, the nursing assistant should report the task to the charge nurse. This is important because the charge nurse can provide guidance on whether the task is appropriate for the nursing assistant to perform. Choice A is incorrect because blindly following a directive that is outside of the nursing assistant's scope could lead to negative consequences. Choice C might not be the best course of action initially, as it's important to seek clarification first. Choice D is also not the best option because performing a task outside of one's role without proper authorization can pose risks to both the patient and the nursing assistant.
A patient with a urinary tract infection (UTI) requires treatment. What is the most appropriate intervention?
- A. Encourage the patient to increase fluid intake.
- B. Administer antibiotics as prescribed.
- C. Recommend the patient take over-the-counter pain relievers.
- D. Encourage the patient to limit physical activity.
Correct Answer: B
Rationale: The correct answer is to administer antibiotics as prescribed. Antibiotics are the primary treatment for urinary tract infections as they help eliminate the bacteria causing the infection. Encouraging the patient to increase fluid intake (Choice A) is a supportive measure to help flush out the bacteria but doesn't directly treat the infection. Over-the-counter pain relievers (Choice C) may help with discomfort but do not address the underlying infection. Limiting physical activity (Choice D) may be recommended for some conditions but is not the primary intervention for treating a UTI.
A healthcare provider gives a verbal order for a medication. The nurse is uncomfortable with the order and questions its appropriateness. What should the nurse do?
- A. Refuse to administer the medication and document the refusal.
- B. Clarify the order with the provider before proceeding.
- C. Administer the medication and monitor the patient.
- D. Call a pharmacy consult to discuss the medication.
Correct Answer: B
Rationale: The correct action for the nurse to take when uncomfortable with a verbal order for medication is to clarify the order with the provider before proceeding. This ensures patient safety by confirming the appropriateness of the order and prevents any potential harm. Choice A is incorrect because refusing to administer the medication without clarification may delay necessary treatment for the patient. Choice C is incorrect as administering the medication without clarification could pose risks if the order is indeed inappropriate. Choice D is also incorrect as the first step should be direct clarification with the provider before involving others.