Nokea
Nurse has prepared sterile field for assisting provider with chest tube insertion. Which should nurse recognize as contaminating sterile field?
- A. Provider drops sterile instrument onto near side of sterile field
- B. Nurse moistens cotton ball with sterile NS & places it on sterile field
- C. Procedure is delayed 1h because provider receives emergency call
- D. Nurse turns to speak to someone who enters through door behind nurse
- E. Client's hand brushes against outer edge of sterile field
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D.
B: Moistening a cotton ball with sterile NS and placing it on the sterile field introduces moisture and potentially non-sterile material, contaminating the field.
C: Delaying the procedure for an hour increases the risk of airborne contaminants settling on the sterile field.
D: Turning to speak to someone who enters behind the nurse can lead to inadvertent contact with non-sterile areas, contaminating the field.
Incorrect choices:
A: While dropping a sterile instrument close to the field is not ideal, it may not necessarily contaminate the field unless it actually touches it.
E: Client's hand brushing against the outer edge of the field is a potential contamination point, but it does not directly contaminate the sterile field.
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Nurse has removed sterile pack from its outside cover & placed it on clean work surface in prep for invasive procedure. Which of following flaps should nurse unfold first?
- A. Flap closest to body
- B. Right side flap
- C. Left side flap
- D. Flap farthest from the body
Correct Answer: D
Rationale: The correct answer is D: Flap farthest from the body. The rationale is to maintain sterility. By unfolding the flap farthest from the body first, the nurse can avoid reaching over the sterile field, minimizing the risk of contamination. This step-by-step approach ensures that the sterile pack remains uncontaminated and ready for the invasive procedure. Unfolding the closest flap, right side flap, or left side flap first would require the nurse to lean over the sterile field, increasing the chances of contamination. Therefore, choosing the flap farthest from the body is the most logical and sterile technique in this situation.
Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: The correct interventions for the nurse to include are A, B, C, and E. A is correct because helping the client see the benefits of their actions can motivate them to engage in health promotion activities. B is important to identify the client's support systems to provide a strong network for the client. C is crucial to suggest and recommend community resources that can further support the client in maintaining cardiovascular health. E is necessary to teach stress management strategies as stress can impact cardiovascular health. Choices D, F, and G are incorrect because setting goals for the client without their input may not be effective, and leaving options blank does not contribute to the client's care plan.
An RN is making assignments for client care to an LPN at the beginning of shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24h post-op to use incentive spirometer
- B. Collecting clean-catch urine specimen
- C. Providing nasopharyngeal suctioning for pneumonia client
- D. Replacing cartridge & tubing on PCA pump
Correct Answer: D
Rationale: The LPN should question replacing cartridge & tubing on PCA pump (Choice D) because this task involves manipulating the patient's medication delivery system, which is beyond the LPN's scope of practice. LPNs are not trained to handle complex medication administration devices like PCA pumps, as this requires a higher level of knowledge and skill typically reserved for RNs. The LPN should advocate for clarification from the RN or delegate this task to someone with the appropriate training. Choices A, B, and C are within the LPN's scope of practice and do not require specialized training like manipulating a PCA pump.
A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?
- A. Each movement is repeated 5 times by the patient.
- B. Each movement is performed until the patient experiences pain.
- C. Each movement is completed quickly and smoothly by the nurse.
- D. Each movement is moved just to the point of resistance by the nurse.
Correct Answer: D
Rationale: The correct answer is D because moving each joint just to the point of resistance during passive ROM exercises helps prevent injury and avoids causing pain to the patient. Moving beyond the point of resistance can result in muscle strain or joint damage. This technique allows the nurse to safely improve joint mobility without causing harm.
Choice A is incorrect because the patient may not be able to repeat the movement 5 times due to their impaired mobility. Choice B is incorrect because continuing movement until the patient experiences pain is harmful and can lead to injury. Choice C is incorrect because moving quickly and smoothly may not allow the nurse to gauge the patient's tolerance and could potentially cause harm.
Nurse caring for client who reports severe sore throat
- A. pain with swallowing
- B. swollen lymph nodes. Client is experiencing which of following stages of infection?
- C. Prodromal
- D. Incubation
- E. Convalescence
Correct Answer: D
Rationale: The correct answer is D: Incubation. The client reporting a severe sore throat indicates that the infection is already present in the body but has not yet manifested with symptoms. During the incubation stage, the pathogen is actively multiplying but the client does not exhibit symptoms yet. Choices A, B, and C (pain with swallowing, swollen lymph nodes, and prodromal stage) all indicate that the infection has progressed beyond the incubation stage and symptoms are present. Choice E (Convalescence) refers to the period of recovery after the infection has been resolved, which is not the case here. Therefore, D is the correct answer as it corresponds to the stage where the client is experiencing symptoms without them being fully manifested yet.