Fundamentals of Nursing Practice Exam 3

EXPLANATION

 

✔Correct answer:

 25G, 5/8 inch long. The appropriate needle size for insulin injections is 25G, 5/8 inch long. Insulin injections are typically given subcutaneously, and a smaller gauge (higher number) and shorter length needle are used to minimize discomfort and ensure the medication is delivered into the subcutaneous tissue rather than deeper into the muscle. A 25-gauge needle is thin enough to cause minimal pain, and a 5/8 inch length is sufficient to reach the subcutaneous tissue in most patients.

Think of the needle size like using a small, precise tool to add a tiny drop of oil to a delicate machine. Using a smaller, shorter tool ensures you place the oil exactly where it's needed without causing damage or discomfort.

Insulin injections require precision and care to ensure effective glucose control and patient comfort. Key considerations for selecting the appropriate needle size include:

1. Needle Gauge (G): The gauge indicates the thickness of the needle. A higher gauge number means a thinner needle, which is less painful and more suitable for subcutaneous injections.
2. Needle Length: The length of the needle should be appropriate to reach the subcutaneous tissue without penetrating into the muscle. For most adults, a 5/8 inch needle is adequate.
3. Injection Technique: Proper technique involves pinching the skin to lift the subcutaneous tissue and inserting the needle at a 45 to 90-degree angle, depending on the patient's body size and the needle length.

 

✘Incorrect answer options:

18G, 1 ½ inches long. This needle is too large in diameter and too long for subcutaneous insulin injections. It is typically used for intramuscular injections or drawing up viscous medications.

22G, 1 inch long. While a 22-gauge needle is thinner than an 18-gauge, it is still thicker than necessary for insulin injections, and a 1-inch length is longer than needed for subcutaneous administration.

22G, 1 ½ inches long. This needle is also too long and thick for insulin injections, making it unsuitable for subcutaneous administration and likely to cause discomfort and improper delivery of insulin.

 

References

• American Diabetes Association. (2020). Standards of Medical Care in Diabetes. Diabetes Care, 43(Supplement 1), S1-S212.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Withhold the medication and immediately inform the physician. The best nursing action when a new skin reaction is observed in a patient scheduled to receive penicillin is to withhold the medication and immediately inform the physician. Penicillin is known for causing allergic reactions, which can range from mild rashes to severe anaphylaxis. Administering the medication without addressing the new skin reaction could lead to a potentially life-threatening allergic response. By withholding the medication and alerting the physician, the nurse ensures patient safety and allows for further assessment and appropriate intervention.

Imagine you notice smoke coming from your car's engine before a long drive. The safest action is to stop driving and call a mechanic for an assessment rather than continuing and risking a fire. Similarly, withholding penicillin and informing the physician prevents potential severe allergic reactions.

Patient safety is a top priority in medication administration. Key steps in managing potential allergic reactions include:

1. Assessment: Recognizing signs and symptoms of allergic reactions, such as new skin rashes.
2. Intervention: Withholding the medication to prevent exacerbating the reaction.
3. Communication: Promptly informing the physician to determine the appropriate course of action.
4. Documentation: Recording the observed reaction and actions taken for ongoing patient care and monitoring.

These steps help ensure that patients receive safe and effective care while minimizing the risk of adverse reactions.

 

✘Incorrect answer options:

Administer the medication and then inform the physician. Administering the medication despite a new skin reaction risks worsening the allergic response and endangering the patient.

Give the medication along with an antihistamine to counteract any potential allergic reaction. This approach is not safe because it does not address the root cause of the reaction and may not prevent a severe allergic response, including anaphylaxis.

Treat the rash locally with cornstarch soaks. Treating the rash topically does not address the potential systemic allergic reaction that penicillin might cause and fails to prevent further complications.

 

References

• Lehne, R. A. (2013). Pharmacology for Nursing Care. St. Louis, MO: Elsevier.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Bile obstruction. The presence of clay-colored stools is a significant indicator of bile obstruction. Bile gives stool its normal brown color. When there is an obstruction in the bile ducts, bile cannot reach the intestines, resulting in stools that are pale, clay-colored, or gray. This condition can occur due to various causes, such as gallstones, tumors, or strictures that block the bile ducts.

Think of bile like a natural dye that colors fabric. If the dye (bile) is blocked from reaching the fabric (stool), the fabric will remain its natural, undyed color (clay-colored stools).

Recognizing the significance of stool color changes is important for diagnosing underlying conditions. Key points include:

1. Bile Function: Bile is produced by the liver and stored in the gallbladder, and it helps digest fats while giving stool its brown color.
2. Causes of Bile Obstruction: Conditions like gallstones, bile duct tumors, strictures, or inflammation can block bile flow, leading to clay-colored stools.
3. Diagnostic Importance: Identifying clay-colored stools can prompt further investigation to diagnose and treat the underlying cause of bile obstruction.

 

✘Incorrect answer options:

Upper gastrointestinal bleeding. Upper GI bleeding typically results in black, tarry stools (melena) due to the digestion of blood as it passes through the gastrointestinal tract.

Impending constipation. Constipation may change stool consistency, but it does not cause clay-colored stools. Stools may be hard and dry but remain brown.

An effect of medication. Some medications can alter stool color, but clay-colored stools specifically indicate a lack of bile, pointing to bile duct obstruction rather than medication effects.

 

References

• Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis, MO: Elsevier.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2017). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Provide additional bedclothes. When a patient experiences chills and shivering due to an infection, it is typically a response to fever. The body is trying to generate and retain heat to increase its temperature to fight off the infection. Providing additional bedclothes helps to keep the patient warm and comfortable, preventing further heat loss and reducing the severity of shivering.

Think of a person who is feeling cold and starts shivering. Giving them a blanket helps them warm up and reduces the shivering, similar to providing additional bedclothes for a patient with chills.

Understanding the physiological response to infection and fever helps in choosing the appropriate nursing intervention. Key points include:

1. Shivering Mechanism: Shivering is a physiological response to generate heat when the body's temperature set point is raised during a fever.
2. Comfort and Warmth: Providing additional bedclothes helps to retain body heat and comfort the patient.
3. Monitoring: Continue to monitor the patient's temperature and overall condition to ensure that the fever and infection are managed effectively.

 

✘Incorrect answer options:

Apply iced alcohol sponges. This intervention is inappropriate as it can cause further chilling and discomfort to the patient who is already experiencing chills and shivering.

Offer increased cool liquids. While hydration is important, offering cool liquids is not the primary intervention to address chills and shivering. Warm fluids would be more appropriate in this context.

Enhance room ventilation. Enhancing room ventilation might lower the room temperature further, exacerbating the patient's chills and shivering. Instead, a warm environment is needed to comfort the patient.

 

References

• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.
• Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

As an IM injection or an IV solution. Parenteral penicillin can be administered either as an intramuscular (IM) injection or as an intravenous (IV) solution. These routes are appropriate because they allow the medication to be absorbed quickly and effectively into the bloodstream, ensuring that therapeutic levels are reached promptly, which is crucial for treating severe infections. IM injections are useful for ensuring slow and steady absorption of the medication, while IV administration provides rapid delivery directly into the bloodstream.

Think of administering penicillin like filling up a car's gas tank. Using an IV route is like using a high-speed pump that fills the tank quickly and gets the car back on the road immediately. An IM injection is like a standard pump, filling the tank steadily for consistent performance.

The choice of administration route for penicillin depends on the severity of the infection, the required speed of drug action, and the patient's condition. Key considerations include:

1. IM Injection: Provides steady absorption over time and is suitable for certain infections where immediate peak levels are not critical.
2. IV Solution: Offers rapid onset of action, ideal for severe infections where immediate therapeutic levels are needed.

 

✘Incorrect answer options:

Either IV or as an intradermal injection. Intradermal injections are not suitable for delivering large volumes of medication or achieving systemic effects quickly, which are necessary for treating severe infections.

Either intradermal or subcutaneous injection. Neither intradermal nor subcutaneous injections provide the appropriate absorption rate or volume capacity required for effectively treating severe infections with penicillin.

As an IM or a subcutaneous injection. While IM injections are suitable, subcutaneous injections do not offer the rapid absorption or volume capacity needed for severe infections.

 

References

• Lehne, R. A. (2013). Pharmacology for Nursing Care. St. Louis, MO: Elsevier.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

During any invasive procedures. Sterile technique, or surgical asepsis, is used during any invasive procedures to prevent the introduction of pathogens into sterile body areas. Invasive procedures involve entering the body, often through a break in the skin or by inserting instruments into sterile body cavities. Examples include surgeries, catheterizations, and the insertion of central lines. Using sterile technique in these situations is critical to preventing infections and ensuring patient safety.

Think of an invasive procedure like performing delicate work inside a sealed, clean environment where no dust or dirt can be allowed. Every tool and surface must be completely clean and free of contaminants to avoid introducing any harmful particles.

Foundational Principles: The principles of surgical asepsis include:

1. Sterilizing all instruments and materials used in the procedure.
2. Maintaining a sterile field where only sterile items are used.
3. Using sterile gloves, gowns, and drapes.
4. Performing proper hand hygiene and using aseptic techniques to prevent contamination.

These measures are essential to protect patients from infections that could arise from introducing pathogens during invasive procedures.

 

✘Incorrect answer options:

When strict isolation of a patient is required. Strict isolation refers to measures taken to prevent the spread of highly contagious diseases. While infection control is critical, it involves barrier precautions and clean techniques rather than sterile techniques unless invasive procedures are being performed.

While conducting terminal disinfection. Terminal disinfection is the thorough cleaning of a patient's room and its contents after the patient is discharged to ensure no infectious agents remain. This process involves environmental cleaning with disinfectants and does not require sterile technique.

When protective isolation of a patient is necessary. Protective isolation is used to protect immunocompromised patients from infection. It involves using clean techniques and barrier precautions, such as wearing masks and gowns, but does not necessitate sterile technique unless performing an invasive procedure.

 

References

• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Presence of hemoglobinuria. Hemoglobinuria, the presence of free hemoglobin in the urine, is a classic sign of a hemolytic reaction to a blood transfusion. During a hemolytic reaction, red blood cells are destroyed (hemolyzed), releasing hemoglobin into the bloodstream, which is then filtered by the kidneys and appears in the urine. This can be detected by a noticeable dark or reddish color of the urine. Hemolytic reactions are serious and can be life-threatening, requiring immediate medical intervention.

Imagine a balloon filled with red dye bursting inside a water tank. The dye would spread throughout the water, turning it red. Similarly, when red blood cells burst, hemoglobin spreads into the bloodstream and is filtered out by the kidneys, appearing in the urine.

Hemolytic transfusion reactions occur when the recipient's immune system attacks the transfused red blood cells. Key symptoms and signs include:

1. Hemoglobinuria: Dark or reddish urine due to the presence of hemoglobin.
2. Back pain: Often due to kidney involvement and hemolysis.
3. Fever and chills: Common early signs of a transfusion reaction.
4. Hypotension: Low blood pressure resulting from the immune response and hemolysis.
5. Tachycardia: Rapid heart rate as the body responds to the reaction.

Immediate cessation of the transfusion and supportive care, including hydration and monitoring of kidney function, are essential steps in managing a hemolytic reaction.

 

✘Incorrect answer options:

Experiencing chest pain. Chest pain can be associated with various types of transfusion reactions, including anaphylactic and febrile non-hemolytic reactions, but it is not specific to hemolytic reactions.

Development of urticaria. Urticaria (hives) is more commonly associated with allergic reactions to transfusions, not hemolytic reactions. It involves an immune response to proteins in the transfused blood.

Appearance of distended neck veins. Distended neck veins are typically associated with fluid overload or congestive heart failure, not specifically with hemolytic transfusion reactions.

 

References

• Hoffbrand, A. V., & Moss, P. A. H. (2016). Essential Haematology. Oxford, UK: Wiley-Blackwell.
• Pagana, K. D., & Pagana, T. J. (2018). Mosby's Diagnostic and Laboratory Test Reference. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

The waist tie and necktie at the back of the gown. When removing a contaminated gown, the first thing the nurse should touch is the waist tie and necktie at the back of the gown. This technique minimizes the risk of self-contamination. By touching and untying the back ties first, the nurse avoids contact with the potentially contaminated front and sleeves of the gown. Once the ties are untied, the nurse can then carefully remove the gown by pulling it away from the body, turning it inside out, and rolling it into a bundle to contain the contaminants inside.

Imagine you are wearing a dirty apron after cooking. To avoid touching the dirty front, you untie the strings at the back first, then pull the apron off by the straps, keeping the dirty part away from your clothes and skin.

The Centers for Disease Control and Prevention (CDC) guidelines for removing personal protective equipment (PPE) emphasize minimizing the risk of self-contamination. The steps for removing a contaminated gown include:

1. Untie the waist and neck ties at the back.
2. Pull the gown away from the body, touching only the inside.
3. Turn the gown inside out during removal.
4. Roll the gown into a bundle, keeping the contaminated side inside.
5. Dispose of the gown in a designated container.

These steps ensure that the nurse minimizes contact with contaminated surfaces and reduces the risk of spreading pathogens.

 

✘Incorrect answer options:

The waist tie at the front of the gown. Touching the waist tie at the front of the gown first can lead to contact with contaminated areas, increasing the risk of self-contamination.

The cuffs of the gown. Starting with the cuffs can also result in self-contamination because the sleeves are likely contaminated. The cuffs should be handled after the ties are undone.

The inside of the gown. While touching the inside of the gown is safe and part of the removal process, it should not be the initial step. The initial step should involve untying the back ties to loosen the gown for safe removal.

 

References

• Centers for Disease Control and Prevention. (2020). How to Remove Personal Protective Equipment (PPE). Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Evaluation. By asking the patient if the pain medication has relieved his pain, Nurse Lopez is engaging in the evaluation step of the nursing process. Evaluation involves assessing the patient's response to the nursing interventions to determine if the desired outcomes have been achieved. In this case, Nurse Lopez is checking whether the pain relief intervention (administration of pain medication) has been effective in reducing the patient's pain.

Think of the nursing process like a cycle of planning a road trip. After planning the route and driving (intervention), you check if you have reached your destination (evaluation). Nurse Lopez is checking if the goal (pain relief) has been achieved.

The nursing process is a systematic method used by nurses to ensure comprehensive and effective patient care. It consists of five steps:

1. Assessment: Collecting data about the patient's health status.
2. Diagnosis (Analysis): Analyzing the assessment data to identify patient problems.
3. Planning: Setting goals and desired outcomes, and planning interventions.
4. Implementation: Carrying out the planned interventions.
5. Evaluation: Assessing the effectiveness of the interventions and determining if the goals have been met.

 

✘Incorrect answer options:

Assessment. Assessment involves collecting data and information about the patient's condition before planning and implementing interventions.

Analysis. Analysis (or diagnosis) involves interpreting assessment data to identify the patient's problems and formulating nursing diagnoses.

Planning. Planning involves setting goals and determining the appropriate nursing interventions to achieve the desired outcomes.

 

References

• Ackley, B. J., & Ladwig, G. B. (2016). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. St. Louis, MO: Elsevier.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Having the patient shower with an antiseptic soap on the evening before and the morning of surgery. The most effective method for skin disinfection before surgery is to have the patient shower with an antiseptic soap on the evening before and the morning of surgery. This practice helps to reduce the microbial load on the skin, thereby decreasing the risk of surgical site infections. Using an antiseptic soap, such as chlorhexidine, is recommended as it is effective in reducing skin bacteria.

Think of preparing the skin for surgery like washing your hands before cooking. Washing thoroughly with soap twice ensures that your hands are as clean as possible, reducing the risk of contaminating the food. Similarly, showering with antiseptic soap twice helps ensure the skin is thoroughly disinfected.

Preoperative skin disinfection is critical for preventing surgical site infections. Key points include:

1. Antiseptic Soap: Using antiseptic soap helps significantly reduce the number of microorganisms on the skin.
2. Timing: Showering both the evening before and the morning of surgery ensures that the skin is as clean as possible at the time of surgery.
3. Technique: Proper showering technique, including thorough washing and rinsing, is important to maximize the effectiveness of the antiseptic soap.

 

✘Incorrect answer options:

Shaving the site on the day before surgery. Shaving can cause microabrasions that increase the risk of infection. If hair removal is necessary, clipping is preferred.

Applying a topical antiseptic to the skin on the evening before surgery. While helpful, this alone is not as effective as showering with antiseptic soap twice.

Having the patient take a tub bath on the morning of surgery. A tub bath does not offer the same level of antimicrobial reduction as showering with antiseptic soap and can also reintroduce bacteria from the bathwater.

 

References

• Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., & Jarvis, W. R. (1999). Guideline for Prevention of Surgical Site Infection. Infection Control and Hospital Epidemiology, 20(4), 247-278.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

A patient with leukopenia.  Leukopenia is a condition characterized by an abnormally low number of white blood cells (WBCs), which are crucial for fighting off infections. A patient with leukopenia has a weakened immune system and is less capable of combating pathogens. This condition significantly compromises the body's defense mechanisms, making the patient highly susceptible to infections. In clinical practice, leukopenic patients often require protective isolation to prevent exposure to infectious agents due to their increased vulnerability.

Think of white blood cells as soldiers in an army that protect a city from invaders. If there are very few soldiers, the city is left defenseless and more likely to be overrun by enemies (pathogens).

White blood cells play a critical role in the immune response by identifying, attacking, and destroying pathogens. Conditions like leukopenia reduce the effectiveness of this immune response, leading to an increased risk of infections. Nursing care for patients with leukopenia includes monitoring for signs of infection, implementing strict hand hygiene, and possibly using protective isolation measures to minimize infection risks. Understanding the significance of leukopenia and its impact on infection risk is fundamental in providing safe and effective care to immunocompromised patients.

 

✘Incorrect answer options:

A patient currently on broad-spectrum antibiotics. While broad-spectrum antibiotics can disrupt the normal flora and potentially lead to secondary infections like Clostridioides difficile, they do not inherently increase the risk of new infections to the same extent as leukopenia. Patients on these antibiotics require monitoring but are not as severely immunocompromised as those with leukopenia.

A postoperative patient from orthopedic surgery. Postoperative patients are indeed at risk for infections, especially at surgical sites, but this risk is generally lower than that of a patient with leukopenia. Proper wound care and monitoring are crucial, but the immune system of a postoperative patient is typically intact unless otherwise compromised.

A newly diagnosed diabetic patient. Diabetic patients are at increased risk for infections due to potential complications such as poor circulation and impaired immune responses. However, this risk is not as immediate or severe as that posed by leukopenia. Proper management of blood glucose levels and regular monitoring can help mitigate infection risks in diabetic patients.

 

References

• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Opening the room door to the hospital corridor. Opening the room door to the hospital corridor is most likely to result in a breach of sterile technique in a respiratory isolation setting. Respiratory isolation aims to prevent the spread of airborne pathogens, which can be easily transported through air currents. By opening the door, air from the corridor, which may contain pathogens, can flow into the isolation room, compromising the sterile environment. This action increases the risk of contamination and infection, undermining the effectiveness of the isolation measures in place to protect both the patient and healthcare workers.

Imagine trying to keep dust out of a room with clean, still air. If you open the door to a hallway with people moving and air circulating, dust and contaminants will inevitably enter the room, despite your efforts to keep it clean.

In maintaining sterile technique, it is critical to control the environment to prevent the introduction of pathogens. The integrity of respiratory isolation depends on minimizing air exchanges between the isolation room and other areas of the hospital. Proper isolation procedures include keeping doors closed, using negative pressure rooms, and ensuring that healthcare workers follow strict protocols for entering and exiting the room. Understanding and adhering to these principles are essential in preventing hospital-acquired infections and protecting vulnerable patients.

 

✘Incorrect answer options:

Opening the window to the outside environment. While opening a window can compromise a sterile environment, it is less likely to happen in modern hospitals where windows are often sealed. Additionally, many isolation rooms are equipped with controlled ventilation systems that mitigate the impact of external air.

Activating the room’s ventilation system. Properly designed ventilation systems in isolation rooms are meant to filter and control airflow, reducing the risk of airborne contamination. Activating the ventilation system should not breach sterile technique if it is functioning correctly.

Omitting gloves during a bed bath. While omitting gloves is a serious breach of infection control protocols and can lead to contamination, it is not specific to the maintenance of respiratory isolation or sterile technique within that context. The more direct concern for sterile technique in a respiratory isolation room is preventing the introduction of airborne pathogens.

 

References

• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Subclavian and jugular veins. The subclavian and jugular veins are the most commonly used blood vessels for the administration of total parenteral nutrition (TPN). These veins provide direct access to the central venous system, allowing the hypertonic TPN solution to be rapidly diluted by the large volume of blood in the superior vena cava. This helps prevent complications such as phlebitis and ensures that the nutrients are quickly delivered to the body.

Think of the subclavian and jugular veins like main highways for delivering essential supplies to a city. These large veins allow the rapid and safe delivery of TPN, similar to how highways facilitate efficient transportation of goods.

Proper site selection for TPN administration is crucial for patient safety and effective treatment. Key points include:

1. Central Venous Access: TPN requires central venous access due to the high concentration of nutrients in the solution.
2. Vein Size and Flow: The subclavian and jugular veins are large and have high blood flow, making them ideal for central venous catheter placement.
3. Complication Prevention: Using these veins helps minimize the risk of phlebitis and ensures rapid dilution of the TPN solution, reducing the potential for complications.

 

✘Incorrect answer options:

Brachial and subclavian veins. The brachial vein is not typically used for TPN because it is a peripheral vein, not a central vein.

Femoral and subclavian veins. While the femoral vein can be used for central venous access, it is not as commonly used as the subclavian and jugular veins for TPN due to a higher risk of infection.

Brachial and femoral veins. Both the brachial and femoral veins are not commonly used together for TPN, as the brachial vein is peripheral, and the femoral vein has a higher risk of infection.

 

References

• Mirtallo, J. M., Canada, T., Johnson, D., Kumpf, V. J., Petersen, C., Sacks, G., & Seres, D. S. (2016). Safe Practices for Parenteral Nutrition. Journal of Parenteral and Enteral Nutrition, 40(4), 496-506.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Hypokalemia. The symptoms of fatigue, muscle cramping, and weakness are indicative of hypokalemia, a common side effect of diuretic therapy, particularly with loop diuretics like furosemide (Lasix). Furosemide increases the excretion of potassium along with sodium and water, leading to a decrease in serum potassium levels. Low potassium levels affect muscle function and can cause the mentioned symptoms.

Think of potassium as a key ingredient in a muscle's "fuel." When a car (muscle) runs low on fuel (potassium), it can't run properly, leading to issues like stalling (cramping) and poor performance (weakness and fatigue).

Hypokalemia is a condition where serum potassium levels fall below the normal range (3.5-5.0 mEq/L). Potassium is crucial for various bodily functions, including muscle contractions, nerve signal transmission, and maintaining proper heart function. Diuretics, particularly loop and thiazide diuretics, can cause potassium loss through urine. Managing and monitoring potassium levels is essential during diuretic therapy to prevent complications.

Symptoms of hypokalemia include:

1. Muscle cramps and weakness: Due to impaired muscle function.
2. Fatigue: From decreased cellular function.
3. Heart arrhythmias: In severe cases, hypokalemia can affect heart rhythm.

Treatment involves:

1. Potassium supplementation: Either orally or intravenously, depending on the severity.
2. Dietary changes: Increasing intake of potassium-rich foods like bananas, oranges, and spinach.
3. Monitoring: Regularly checking serum potassium levels to ensure they remain within the normal range.

 

✘Incorrect answer options:

Hyperkalemia (high potassium levels) typically presents with symptoms such as irregular heartbeat, palpitations, and muscle weakness, but not muscle cramping. It is less common with furosemide use, which tends to lower potassium levels.

Anorexia (loss of appetite) can be a side effect of many conditions but does not specifically cause muscle cramping, weakness, or fatigue in the context of diuretic therapy.

Dysphagia (difficulty swallowing) is unrelated to the symptoms of muscle cramping, weakness, and fatigue and is not a common side effect of furosemide.

 

References

• Hoffbrand, A. V., & Moss, P. A. H. (2016). Essential Haematology. Oxford, UK: Wiley-Blackwell.
• Pagana, K. D., & Pagana, T. J. (2018). Mosby's Diagnostic and Laboratory Test Reference. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Applying lotion while massaging the reddened area. Applying lotion while massaging a reddened area is not advised for preventing pressure ulcers. Massaging a reddened area, especially one that indicates the beginning stages of a pressure ulcer (Stage 1), can cause further damage to the underlying tissues. This action can exacerbate the condition by increasing pressure and friction on already compromised skin and tissue.

Imagine you have a bruise on an apple. Rubbing or pressing on the bruise can make it worse and cause the apple to break down more quickly. Similarly, massaging a reddened area on the skin can cause more damage.

Preventing pressure ulcers involves several critical practices aimed at reducing pressure, friction, and moisture:

1. Using pressure-relieving devices: Water or air mattresses can help distribute weight and reduce pressure on vulnerable areas.
2. Repositioning and turning: Following a strict regimen for repositioning and turning the patient at regular intervals helps alleviate prolonged pressure on any one area.
3. Diligent skin care: Maintaining clean and dry skin, inspecting for early signs of pressure damage, and using appropriate moisturizers can prevent skin breakdown.

These measures are essential in a comprehensive approach to pressure ulcer prevention and promote overall skin integrity.

 

✘Incorrect answer options:

Utilizing a water or air mattress to reduce pressure. This measure is advised and effective in preventing pressure ulcers by redistributing weight and reducing pressure on susceptible areas of the body.

Following a strict regimen for repositioning and turning the patient. Regular repositioning and turning of patients are crucial practices in preventing pressure ulcers. It helps in alleviating constant pressure on any one part of the body.

Executing diligent skin care routines. Proper skin care routines, including keeping the skin clean, dry, and moisturized, are essential in preventing pressure ulcers. Regular inspection of the skin helps in early detection and intervention.

 

References

• National Pressure Injury Advisory Panel (2019). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. Retrieved from https://npiap.com/.
• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.

EXPLANATION

 

✔Correct answer:

Disposing of all used uncapped needles and syringes into a puncture-resistant container. Disposing of all used uncapped needles and syringes into a puncture-resistant container is considered the most effective form of universal precautions. This practice significantly reduces the risk of needlestick injuries, which are a major route of transmission for bloodborne pathogens, including HIV and hepatitis B and C. By immediately placing used needles into a designated sharps container, healthcare workers minimize their risk of accidental exposure and ensure safe disposal of potentially infectious materials.

Think of used needles like broken glass. You wouldn’t leave broken glass lying around or try to handle it with your bare hands. Instead, you would carefully place it into a thick, secure container to prevent anyone from getting hurt.

Universal precautions, now part of Standard Precautions, are designed to prevent the transmission of infectious agents. Key principles include:

1. Hand hygiene: Regular and thorough washing or sanitizing of hands.
2. Use of personal protective equipment (PPE): Including gloves, gowns, masks, and eye protection.
3. Safe injection practices: Using and disposing of needles and syringes appropriately.
4. Sharps safety: Immediate disposal of used sharps in puncture-resistant containers.
5. Environmental cleaning: Regular disinfection of surfaces and equipment.
6. Respiratory hygiene: Cough etiquette and mask usage.

Disposing of used needles and syringes in puncture-resistant containers is a cornerstone of sharps safety, preventing injuries and the potential spread of infections.

 

✘Incorrect answer options:

Capping all used needles before detaching them from their syringes. Capping needles after use, also known as "recapping," is strongly discouraged due to the high risk of needlestick injuries during the capping process. Safe disposal without recapping is the recommended practice.

Wearing gloves during the administration of intramuscular (IM) injections. While wearing gloves is an important aspect of infection control, it is not the most critical intervention among the given options. Gloves protect the healthcare worker but do not address the safe disposal of needles, which is crucial for preventing injuries.

Adhering to enteric precautions. Enteric precautions are specific to preventing the spread of gastrointestinal infections and are not part of universal precautions, which aim to prevent the transmission of bloodborne pathogens and other infectious agents through standard practices.

 

References

• Centers for Disease Control and Prevention. (2020). Standard Precautions for All Patient Care. Retrieved from https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html.
• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.

EXPLANATION

 

✔Correct answer:

Leg muscles. When assisting a patient from the bed to a chair, Nurse Lopez should primarily use her leg muscles to avoid back injury. The leg muscles are the strongest muscles in the body and are well-suited to handle the weight and force required for lifting and moving patients. By using her legs, Nurse Lopez can maintain proper body mechanics, reduce the strain on her back, and minimize the risk of injury.

Think of lifting a heavy box from the floor. Bending your knees and using your legs to lift keeps your back straight and prevents injury, just like using your leg muscles to assist a patient.

Foundational Principles: Proper body mechanics are essential in nursing to prevent injuries. Key points include:

1. Using Leg Muscles: These muscles are strong and can handle the stress of lifting.
2. Keeping the Back Straight: This reduces the risk of back strain and injury.
3. Bending the Knees: This technique ensures that the lifting force comes from the legs rather than the back.

 

✘Incorrect answer options:

Abdominal muscles. While abdominal muscles help stabilize the core, they are not the primary muscles used for lifting heavy weights.

Back muscles. Using the back muscles to lift can lead to strain and injury. It is important to avoid using the back as the primary lifting source.

Upper arm muscles. While upper arm muscles are involved in handling and positioning, they are not the primary muscles used for lifting the body weight of a patient.

 

References

• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.
• Tornvall, G., Wahren, L. K., Wilhelmsson, S., & Nieminen, H. (2002). Effect of education on patient transfer tasks and musculoskeletal health among nursing personnel. Ergonomics, 45(11), 773-783.

EXPLANATION

 

✔Correct answer:

A WBC count of 25,000 cells per cubic millimeter. Leukocytosis is defined as an elevated white blood cell (WBC) count, typically above 11,000 cells per cubic millimeter. A WBC count of 25,000 cells per cubic millimeter is significantly higher than the normal range (4,500 to 11,000 cells per cubic millimeter), indicating a clear case of leukocytosis. This condition can be caused by various factors, including infections, inflammation, stress, leukemia, and other medical conditions. It is important to investigate the underlying cause of leukocytosis to provide appropriate treatment and management.

Think of WBCs as the body's defense troops. Normally, the body has a certain number of troops ready to fight off invaders. If the number suddenly spikes to much higher levels, it signals that the body is responding to a significant threat, like an infection or inflammation.

Understanding WBC counts is crucial for diagnosing and managing various medical conditions. The normal range for WBC counts is typically between 4,500 and 11,000 cells per cubic millimeter. Values above this range indicate leukocytosis, while values below this range suggest leukopenia (low WBC count). The causes of leukocytosis can include:

1. Infections: Bacterial, viral, or fungal infections often trigger an increase in WBC count.
2. Inflammation: Conditions like rheumatoid arthritis or inflammatory bowel disease can cause elevated WBC counts.
3. Stress: Physical or emotional stress can lead to temporary increases in WBC count.
4. Bone Marrow Disorders: Conditions like leukemia or myeloproliferative disorders can cause significant elevations in WBC count.

Proper interpretation of WBC counts, along with clinical evaluation, helps guide the diagnosis and treatment of underlying conditions.

 

✘Incorrect answer options:

A WBC count of 4,500 cells per cubic millimeter. This value is at the lower end of the normal range and does not indicate leukocytosis. It is considered a normal WBC count.

A WBC count of 7,000 cells per cubic millimeter. This value falls within the normal range and does not indicate leukocytosis. It represents a typical WBC count for a healthy individual.

A WBC count of 10,000 cells per cubic millimeter. This value is also within the normal range, although it is on the higher end. It does not indicate leukocytosis and is generally considered a normal WBC count.

 

References

• Hoffbrand, A. V., & Moss, P. A. H. (2016). Essential Haematology. Oxford, UK: Wiley-Blackwell.
• Pagana, K. D., & Pagana, T. J. (2018). Mosby's Diagnostic and Laboratory Test Reference. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Respiratory acidosis, atelectasis, and hypostatic pneumonia. Prolonged immobility can lead to several respiratory complications due to altered lung ventilation. These include:

1. Respiratory Acidosis: This occurs when hypoventilation leads to an accumulation of carbon dioxide in the blood, resulting in a lower pH.
2. Atelectasis: Prolonged immobility can cause collapse of the alveoli, leading to reduced lung volume and gas exchange.
3. Hypostatic Pneumonia: Immobility can result in decreased lung expansion and mucus clearance, creating a favorable environment for bacterial growth and infection.

Think of the lungs as a balloon that needs to be inflated regularly. If the balloon is left unused and deflated (immobility), it can collapse and collect dust (atelectasis and hypostatic pneumonia). Keeping it inflated (regular movement and breathing exercises) helps maintain its shape and cleanliness.

Understanding the impact of immobility on respiratory function is crucial for preventing complications. Key points include:

1. Lung Expansion: Regular movement and deep breathing exercises help maintain lung expansion and prevent atelectasis.
2. Mucus Clearance: Encouraging coughing and the use of incentive spirometry can help clear mucus and prevent infections.
3. Monitoring: Regularly monitoring respiratory status and implementing interventions to promote lung function are essential in immobilized patients.

✘Incorrect answer options:

Apneustic breathing, atypical pneumonia, and respiratory alkalosis. Apneustic breathing is characterized by prolonged inspiratory phases, which is not typically related to immobility. Atypical pneumonia is a type of lung infection but is not specifically related to immobility. Respiratory alkalosis is caused by hyperventilation, which is not a common result of immobility.

Cheyne-Stokes respirations and spontaneous pneumothorax. Cheyne-Stokes respirations are a pattern of periodic breathing, often associated with severe heart failure or brain injury, not immobility. Spontaneous pneumothorax is a collapsed lung due to air entering the pleural space, not typically related to immobility.

Kussmaul’s respirations and hypoventilation. Kussmaul’s respirations are deep, rapid breathing associated with metabolic acidosis, such as in diabetic ketoacidosis. Hypoventilation can occur with immobility but is not paired with Kussmaul’s respirations in this context.

 

References

• Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis, MO: Elsevier.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2017). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Allergy. The development of hives after the administration of an antibiotic is indicative of an allergic reaction. Allergies occur when the immune system responds abnormally to a foreign substance, such as a drug. Common symptoms of a drug allergy include hives (urticaria), itching, rash, swelling, and in severe cases, anaphylaxis. This type of hypersensitivity reaction involves the immune system producing antibodies against the drug, leading to the release of histamines and other chemicals that cause allergic symptoms.

Imagine the immune system as a security team. When an intruder (allergen) is detected, the security team overreacts, causing unnecessary alarms and chaos (allergic reaction), even if the intruder is not harmful.

Recognizing and managing drug allergies is crucial in clinical practice to ensure patient safety and prevent severe reactions. Key aspects include:

1. Identification of Symptoms: Noting signs like hives, rash, itching, and swelling.
2. Immediate Response: Stopping the offending drug and providing appropriate treatment, such as antihistamines or corticosteroids.
3. Documentation and Communication: Recording the allergy in the patient's medical record and informing all healthcare providers to avoid future administration of the allergenic drug.

 

✘Incorrect answer options:

Tolerance. Tolerance refers to a decreased response to a drug over time, requiring higher doses to achieve the same effect. It does not involve an immune response or allergic symptoms.

Idiosyncrasy. Idiosyncratic reactions are unusual or unexpected drug responses that occur in a small percentage of the population and are not related to the drug's typical pharmacological action. They do not typically involve immune mechanisms or allergic symptoms.

Synergism. Synergism occurs when two drugs produce a combined effect greater than the sum of their individual effects. This is a pharmacodynamic interaction and does not relate to allergic reactions or immune responses.

 

References

• Lehne, R. A. (2013). Pharmacology for Nursing Care. St. Louis, MO: Elsevier.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Approximately 25 drops per minute. To calculate the flow rate in drops per minute, you can use the following formula:

Flow rate (drops/min) = (Volume to be infused (ml/hour) × Drop factor (drops/ml)) / 60 (minutes/hour)

Given:

• Volume to be infused = 100 ml/hour
• Drop factor = 15 drops/ml

Substitute these values into the formula:

• Flow rate (drops/min) = (100 ml/hour × 15 drops/ml) / 60 minutes/hour
• Flow rate (drops/min) = 1500 drops / 60 minutes
• Flow rate (drops/min) = 25 drops/min

Thus, the correct flow rate is approximately 25 drops per minute.

Imagine you need to water a plant using a watering can that releases a specific number of drops per minute. If the can releases 15 drops per milliliter and you need to give the plant 100 milliliters of water per hour, you would adjust the flow to ensure the plant gets the right amount steadily. Calculating the exact drops per minute ensures precise watering.

Accurate calculation of IV flow rates is critical in ensuring patients receive the correct amount of medication or fluids. This requires understanding the relationship between volume, time, and the drop factor of the IV set. By applying the appropriate formula, nurses can ensure safe and effective infusion therapy.

 

✘Incorrect answer options:

Roughly 5 drops per minute. This value is too low and does not match the required flow rate.

About 13 drops per minute. This value is too low and does not match the required flow rate.

Around 50 drops per minute. This value is too high and exceeds the required flow rate.

 

References

• Lehne, R. A. (2013). Pharmacology for Nursing Care. St. Louis, MO: Elsevier.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Experiencing Renal Failure. Patients experiencing renal failure often require careful fluid management and may necessitate fluid restrictions. In renal failure, the kidneys' ability to filter and excrete excess fluids is compromised, leading to fluid overload, edema, and potentially life-threatening complications such as pulmonary edema or hypertension. Managing fluid intake helps prevent these issues by reducing the volume that the kidneys need to process and maintain a balance of fluids in the body.

 Imagine a sink with a very slow drain. If you keep pouring water into the sink at a normal rate, it will quickly overflow. To prevent this, you need to control how much water you add, ensuring the sink can handle it without spilling over.

Fluid management is critical in conditions where the body's ability to maintain fluid balance is impaired. For patients with renal failure:

1. Monitoring Intake and Output: Keeping track of all fluids taken in and excreted to prevent fluid overload.
2. Daily Weights: Regularly weighing the patient to detect fluid retention early.
3. Dietary Restrictions: Limiting sodium and fluid intake to reduce fluid retention and blood pressure.

Proper fluid management is crucial to prevent complications and ensure patient stability.

 

✘Incorrect answer options:

Presenting with fever. While fever can increase fluid needs due to increased sweating and insensible losses, it typically does not require fluid restriction. Instead, maintaining adequate hydration is crucial.

Having Chronic Obstructive Pulmonary Disease. COPD may require careful management of fluids to avoid fluid overload, particularly if there is concurrent heart failure, but it does not typically necessitate strict fluid restriction like renal failure.

Suffering from Dehydration. Dehydration requires increasing fluid intake to restore normal fluid balance, not restricting it. Proper hydration is essential to correct the fluid deficit.

 

References

• Kimmel, P. L., & Rosenberg, M. E. (2018). Chronic Renal Disease. Amsterdam, Netherlands: Elsevier.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2017). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Early in the morning. The optimal time to collect a sputum specimen for culture is early in the morning. This is because sputum tends to accumulate in the respiratory tract overnight, making it easier to expectorate a sample that is rich in pathogens and cellular debris. Collecting the specimen in the morning before the patient eats or drinks helps to ensure that the sample is not contaminated with food particles or oral flora, which can interfere with the culture results.

Think of collecting a sputum sample like gathering dew from grass early in the morning. Overnight, dew accumulates, making it easy to collect a pure sample first thing in the morning. As the day progresses, the dew evaporates and mixes with other particles, making it harder to gather a clean and uncontaminated sample. Similarly, sputum accumulates in the respiratory tract overnight, making morning the best time to collect an accurate specimen.

Proper timing and technique for sputum collection are essential to obtain an accurate and uncontaminated sample for diagnostic purposes. The key steps include:

1. Timing: Collecting the sample first thing in the morning before the patient has had anything to eat or drink.
2. Preparation: Ensuring the patient understands how to produce a deep cough to bring up sputum from the lower respiratory tract.
3. Avoiding Contamination: Instructing the patient to rinse their mouth with water before collecting the specimen to reduce contamination from oral flora.

These steps help ensure that the sputum sample is representative of the respiratory tract's condition and suitable for accurate microbiological analysis.

 

✘Incorrect answer options:

Shortly after the patient has eaten a light breakfast. Collecting a sputum sample after eating increases the risk of contamination with food particles and oral flora, which can affect the accuracy of the culture results.

Following aerosol therapy. While aerosol therapy can help loosen secretions, it is not the optimal time for sputum collection for culture because the sample may still be mixed with the medication used in the aerosol therapy, potentially affecting the culture results.

Following chest physiotherapy. Chest physiotherapy can help mobilize secretions, making it easier to expectorate sputum. However, the optimal time for collecting a specimen is still early in the morning before any interventions or meals to ensure the sample's purity and accuracy.

 

References

• Pagana, K. D., & Pagana, T. J. (2018). Mosby's Diagnostic and Laboratory Test Reference. St. Louis, MO: Elsevier.
• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.

EXPLANATION

 

✔Correct answer:

Keep the drainage tubing and collection bag below bladder level to promote drainage by gravity. The primary nursing intervention necessary for all patients with a Foley catheter in place is to keep the drainage tubing and collection bag below bladder level to promote drainage by gravity. This positioning helps ensure that urine flows freely from the bladder into the collection bag, reducing the risk of urine backflow, which can lead to urinary tract infections (UTIs) and other complications.

Think of the catheter like a rain gutter system on a house. To ensure water flows away from the roof effectively, the gutter must slope downward. Similarly, keeping the catheter bag below bladder level ensures that urine flows smoothly by gravity.

Proper management of a Foley catheter is essential to prevent complications such as UTIs, bladder distension, and catheter blockages. Key points include:

1. Gravity Drainage: Ensuring that the collection bag is always below bladder level helps facilitate continuous urine flow.
2. Preventing Backflow: Positioning the bag correctly prevents urine from flowing back into the bladder, which can introduce bacteria and cause infections.
3. Monitoring and Hygiene: Regularly monitoring the catheter and maintaining good hygiene practices are essential to prevent infections and other complications.

 

✘Incorrect answer options:

Keep the drainage tubing and collection bag level with the patient’s bladder. This positioning can lead to urine backflow and increase the risk of infection.

Irrigate the catheter with 1% Neosporin solution three times daily. Routine irrigation with an antibiotic solution is not a standard practice and can increase the risk of introducing bacteria or causing irritation.

Clamp the catheter for 1 hour every 4 hours to help maintain bladder elasticity. Clamping the catheter is not a standard practice for maintaining bladder elasticity and can lead to complications such as bladder distension and increased risk of infection.

 

References

• Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., & Pegues, D. A. (2017). Guideline for Prevention of Catheter-Associated Urinary Tract Infections. Infection Control and Hospital Epidemiology, 38(5), 557-579.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

The inside of the glove is sterile. The statement "The inside of the glove is sterile" is not true. The inside of sterile gloves is not considered sterile once touched by hands during the donning process. When donning sterile gloves, the outer surface is sterile, but the inside of the glove, which comes into contact with the skin of the hands, is considered non-sterile. This distinction is crucial to understand to maintain the integrity of the sterile field.

Think of sterile gloves like a clean sandwich bag. The outside of the bag (sterile glove) is clean, but once you put your hand inside the bag, the part touching your hand is no longer clean (non-sterile).

Proper donning of sterile gloves involves the following steps to ensure that the sterile field is maintained:

1. Pick up the first glove by holding the inside of the cuff: This prevents contamination of the outside of the glove.
2. Slip the gloved fingers underneath the outside of the cuff for the second glove: This technique ensures that the sterile part of the glove touches only the sterile outside of the other glove.
3. Adjust the gloves by sliding the gloved fingers under the sterile cuff: This helps pull the glove over the wrist without contaminating the sterile surface.

Understanding and adhering to these principles is crucial for maintaining sterility during procedures.

 

✘Incorrect answer options:

The first glove should be picked up by holding the inside of the cuff. This statement is true. Picking up the first glove by holding the inside of the cuff prevents the sterile part of the glove from being contaminated.

The second glove should be picked up by slipping the gloved fingers underneath the outside of the cuff. This statement is true. Using the gloved fingers to slip underneath the cuff of the second glove helps maintain sterility.

Adjusting the gloves involves sliding the gloved fingers under the sterile cuff to pull the glove over the wrist. This statement is true. Adjusting the gloves in this manner helps ensure the sterile part of the glove is not contaminated.

 

References

• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

An impaired or traumatized blood vessel wall. Thrombophlebitis typically develops in patients with an impaired or traumatized blood vessel wall. This condition involves inflammation of a vein along with the formation of a blood clot. Damage to the blood vessel wall can result from various factors such as intravenous catheters, trauma, surgery, or certain medical conditions. This damage triggers the clotting mechanism, leading to thrombus formation and subsequent inflammation of the vein.

Think of a water pipe that has been scratched or damaged. The damaged area can attract debris and cause a blockage. Similarly, a damaged blood vessel wall can attract blood cells and lead to clot formation, resulting in thrombophlebitis.

Understanding the risk factors and mechanisms leading to thrombophlebitis is crucial for prevention and management. Key points include:

1. Vessel Wall Damage: Trauma, surgery, and IV catheters can damage the blood vessel wall, increasing the risk of clot formation.
2. Clot Formation: The body's clotting mechanism is activated when the vessel wall is damaged, leading to thrombus formation.
3. Inflammation: The presence of a thrombus in the vein triggers an inflammatory response, causing thrombophlebitis.

 

✘Incorrect answer options:

Increased partial thromboplastin time. Increased partial thromboplastin time (PTT) is associated with a reduced tendency to form clots, as it indicates prolonged clotting time, which is not a typical risk factor for thrombophlebitis.

Acute pulsus paradoxus. Pulsus paradoxus is a condition associated with changes in blood pressure during breathing and is not directly related to thrombophlebitis or clot formation.

Chronic Obstructive Pulmonary Disease (COPD). While COPD can lead to complications related to circulation and blood flow, it is not a primary risk factor for the development of thrombophlebitis.

 

References

• Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis, MO: Elsevier.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2017). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Order a hemoglobin and hematocrit count 1 hour after the arteriography. Ordering a hemoglobin and hematocrit count 1 hour after the arteriography is not a standard post-procedure intervention unless there are specific indications such as signs of significant bleeding or hemodynamic instability. Routine post-arteriography care focuses on monitoring for complications such as bleeding, hematoma formation, and ensuring adequate circulation to the affected limb.

Imagine checking a car’s engine right after a long drive to ensure everything is working well. You wouldn’t test the oil level unless there was a leak or other problem; instead, you would check for signs of overheating or strange noises.

Post-arteriography care involves close monitoring to detect and address complications early. Key interventions include:

1. Assessing pulses: Checking femoral, popliteal, and pedal pulses ensures adequate blood flow and helps detect potential complications such as thrombosis or occlusion.
2. Checking the pressure dressing: Monitoring for signs of sanguineous drainage helps identify bleeding at the puncture site.
3. Monitoring vital signs: Frequent monitoring of vital signs helps detect early signs of complications such as hypotension or tachycardia, which can indicate bleeding or other issues.

These interventions are essential to ensure patient safety and detect complications early.

 

✘Incorrect answer options:

Assess femoral, popliteal, and pedal pulses every 15 minutes for the first 2 hours. This is an appropriate and necessary intervention to ensure adequate circulation and detect potential complications.

Check the pressure dressing for any signs of sanguineous drainage. This is an appropriate intervention to monitor for bleeding at the puncture site.

Monitor vital signs every 15 minutes for the initial 2 hours. This is an appropriate intervention to monitor for hemodynamic stability and detect early signs of complications.

 

References

• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2017). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. St. Louis, MO: Elsevier.
• Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Acts as a protective response to expel irritants from the respiratory tract. A cough is primarily a protective reflex that helps expel irritants, mucus, and foreign particles from the respiratory tract. This mechanism is crucial for maintaining clear airways and preventing infections. When irritants such as dust, smoke, or pathogens stimulate the cough receptors in the respiratory tract, a signal is sent to the brain, which then triggers the muscles of the respiratory system to expel the irritants forcefully through coughing.

Think of a cough like a fire alarm in a building. When smoke or irritants (like smoke) are detected, the alarm goes off (cough reflex) to alert and expel the irritants (clear the airways) to protect the building (respiratory system).

Understanding the purpose and mechanism of a cough is important for both patients and healthcare providers. Key points include:

1. Protective Mechanism: Coughing helps keep the airways clear by removing irritants and secretions.
2. Involuntary Reflex: While coughing can be voluntary, it is mostly an involuntary reflex initiated by the nervous system in response to irritation.
3. Importance in Health: Effective coughing is vital in preventing respiratory infections and maintaining clear airways.

 

✘Incorrect answer options:

Is mostly a voluntary action. Although coughing can be voluntary, it is predominantly an involuntary reflex that occurs automatically in response to irritants in the respiratory tract.

Is triggered by taking an antitussive medication. Antitussive medications are designed to suppress coughing, not trigger it. They are used to reduce the frequency and intensity of coughing.

Can be stopped by “splinting” the abdomen. Splinting the abdomen (applying pressure to the abdomen) can help reduce pain while coughing, especially after abdominal surgery, but it does not stop the cough reflex itself.

 

References

• Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis, MO: Elsevier.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Split the area between the greater femoral trochanter and the lateral femoral condyle into thirds and use the middle third on the front of the thigh. The correct method to identify the vastus lateralis site for an intramuscular injection involves splitting the area between the greater femoral trochanter and the lateral femoral condyle into thirds and using the middle third on the front of the thigh. This area is recommended because it provides a large, well-defined muscle mass that is safe for intramuscular injections, minimizing the risk of hitting nerves or blood vessels.

Think of finding the vastus lateralis site like locating the middle portion of a ruler between two marked points. By dividing the ruler into three equal parts and selecting the middle part, you ensure accuracy and safety in placement.

The vastus lateralis muscle is a preferred site for intramuscular injections, especially in children and adults, because it is a large, thick muscle that can absorb larger volumes of medication. Proper technique includes:

1. Positioning the patient comfortably: The patient can be in a seated or lying position.
2. Identifying anatomical landmarks: The greater femoral trochanter (near the hip) and the lateral femoral condyle (near the knee).
3. Dividing the distance: Split the distance between these landmarks into thirds and use the middle third for the injection site.
4. Ensuring safety: Avoiding major nerves and blood vessels that are less prominent in this muscle area.

 

✘Incorrect answer options:

Identify the upper section of the upper outer quadrant of the buttock, about 5 to 8 cm below the iliac crest. This method describes the dorsogluteal site, which is less frequently used due to the risk of hitting the sciatic nerve.

Feel for the lower edge of the acromion process and the midpoint on the lateral side of the arm. This describes the deltoid site, which is suitable for smaller volume injections but not the vastus lateralis.

Locate a 1-inch circular area just in front of the umbilicus. This is incorrect for intramuscular injections and is not a recognized site for such injections.

 

References

• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.
• Lehne, R. A. (2013). Pharmacology for Nursing Care. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Completed a master’s degree in the prescribed clinical area and is a registered professional nurse. A Clinical Nurse Specialist (CNS) is an advanced practice registered nurse (APRN) who has completed a master’s degree or higher in a specific clinical area. This advanced education prepares the CNS to provide expert clinical care, conduct research, educate and support nursing staff, and lead improvements in healthcare practices within their specialty. The qualifications ensure that a CNS is equipped with the knowledge and skills required to excel in a specialized area of nursing and contribute significantly to patient care and healthcare systems.

Think of a CNS like a specialized chef who has completed advanced training in a particular cuisine. This chef not only cooks but also teaches others, improves recipes, and ensures high standards in the kitchen. Similarly, a CNS provides specialized care, supports other nurses, and enhances healthcare practices.

Foundational Principles: The role of a CNS encompasses several key areas:

1. Expert Clinical Practice: Providing direct patient care and managing complex cases within their specialty.
2. Education: Educating and mentoring nursing staff to improve clinical skills and knowledge.
3. Research and Evidence-Based Practice: Conducting and applying research to enhance patient care and outcomes.
4. Leadership and Consultation: Leading initiatives to improve healthcare practices and serving as a consultant within their area of expertise.

 

✘Incorrect answer options:

Been certified by the National League for Nursing. Certification by the National League for Nursing (NLN) pertains to nursing education and does not specifically qualify a nurse as a Clinical Nurse Specialist.

Received credentials from the Philippine Nurses’ Association. Credentials from the Philippine Nurses’ Association are relevant in the Philippines but do not define a CNS, which requires advanced education and certification in a clinical specialty area.

Graduated from an associate degree program and is a registered professional nurse. An associate degree in nursing (ADN) qualifies one to become a registered nurse (RN) but does not meet the advanced educational requirements needed to become a CNS.

 

References

• Hamric, A. B., Hanson, C. M., Tracy, M. F., & O’Grady, E. T. (2014). Advanced Practice Nursing: An Integrative Approach. St. Louis, MO: Elsevier.
• American Nurses Association. (2015). Nursing: Scope and Standards of Practice. Silver Spring, MD: ANA.

EXPLANATION

 

✔Correct answer:

The portal of entry. Maintaining skin integrity directly affects the portal of entry in the circular chain of infection. The skin serves as a primary barrier against pathogens. If the skin remains intact and unbroken, it prevents microorganisms from entering the body, thereby eliminating the portal of entry for potential infections. By doing so, the chain of infection is disrupted, and the spread of infection can be effectively controlled. The concept of the chain of infection highlights that breaking just one link can halt the entire process, and in this case, maintaining skin integrity effectively breaks the link of the portal of entry.

Think of your skin as a fortress wall that keeps invaders out. If the wall has no cracks or breaches, invaders cannot get in. Similarly, intact skin prevents harmful pathogens from entering your body and causing infections.

The skin is a crucial part of the body's first line of defense in the immune system. By maintaining skin integrity, healthcare providers can prevent microorganisms from bypassing this protective barrier. This practice is fundamental in infection control, particularly in settings where patients may have compromised immune systems or open wounds. Preventative measures include proper wound care, regular skin assessments, and appropriate use of moisturizers to keep the skin healthy and intact. Understanding and implementing these measures are essential skills in nursing practice to promote patient safety and reduce the risk of healthcare-associated infections.

 

✘Incorrect answer options:

The host. While maintaining skin integrity does protect the host (the patient), it does not directly eliminate the host as a link in the chain of infection. The host is always present in the chain, but interventions are aimed at protecting the host from becoming susceptible.

The reservoir. The reservoir is where pathogens live and multiply, such as in humans, animals, or the environment. Maintaining skin integrity does not directly affect the reservoir. Measures like proper cleaning and disinfection, hand hygiene, and controlling environmental conditions are necessary to manage reservoirs.

The mode of transmission. This refers to how pathogens are spread from one place to another, such as through direct contact, droplets, or vectors. While intact skin can prevent pathogens from entering the body, it does not directly influence how the pathogens are transmitted. Hand hygiene, sterilization of instruments, and isolation precautions are methods used to control the mode of transmission.

 

References

• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

All of the choices. The ELISA (Enzyme-Linked Immunosorbent Assay) test is a versatile diagnostic tool used for multiple purposes related to the detection of antibodies against various pathogens, including HIV. Specifically, the ELISA test can be used to:

1. Screen blood donors for antibodies to human immunodeficiency virus (HIV): This helps ensure that donated blood is free from HIV infection, making it safe for recipients.
2. Test blood intended for transfusion for HIV antibodies: This is a critical step in the blood transfusion process to prevent the transmission of HIV through contaminated blood.
3. Aid in diagnosing a patient with AIDS: By detecting the presence of HIV antibodies in a patient's blood, the ELISA test assists in diagnosing HIV infection and, subsequently, AIDS if the infection progresses.

Think of the ELISA test like a highly sensitive alarm system that can detect specific intruders (antibodies) in a building (the body). It can be used in various scenarios: ensuring the building is secure (screening blood donors), checking items before they enter the building (testing transfusion blood), and identifying intruders already inside (diagnosing HIV/AIDS).

The ELISA test is a widely used immunological assay due to its sensitivity and specificity. Key points include:

1. Detection of Antibodies: The test identifies specific antibodies in the blood, indicating exposure to particular pathogens like HIV.
2. Multiple Applications: It is used in blood donor screening, blood transfusion safety, and patient diagnosis.
3. Preventive and Diagnostic Tool: ELISA helps prevent the spread of infections through transfusions and aids in the early diagnosis and management of infectious diseases.

 

✘Incorrect answer options:

The individual options are not incorrect but rather incomplete. The ELISA test is used for all the listed purposes.

 

References

• Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., & Pegues, D. A. (2017). Guideline for Prevention of Catheter-Associated Urinary Tract Infections. Infection Control and Hospital Epidemiology, 38(5), 557-579.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

600 mg. To convert grains to milligrams, it's important to know that 1 grain is equivalent to approximately 60 milligrams. Therefore, to convert 10 grains to milligrams, you multiply 10 by 60.

10 grains × 60 mg/grain=600 mg

Thus, 10 grains of aspirin is equivalent to 600 milligrams.

Think of converting grains to milligrams like converting dollars to cents. Just as you multiply the number of dollars by 100 to get cents, you multiply the number of grains by 60 to get milligrams.

Understanding dosage conversions is critical in ensuring accurate medication administration. The conversion factor between grains and milligrams is a standard value used in pharmacology to help healthcare providers correctly interpret and administer dosages prescribed by physicians.

 

✘Incorrect answer options:

0.6 mg. This is incorrect because it does not account for the proper conversion factor. It is far too low a dosage.

10 mg. This is incorrect because it is the same number as the original dosage in grains, not converted.

60 mg. This is incorrect because it only represents 1 grain, not 10 grains.

 

References

• Lehne, R. A. (2013). Pharmacology for Nursing Care. St. Louis, MO: Elsevier.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Ask the patient to perform a demonstration of the procedure. The best method to confirm the patient has understood and can perform the instillation of ear medication correctly is to ask the patient to perform a demonstration of the procedure. This approach, known as the "teach-back" or "show-me" method, allows Nurse Allen to directly observe the patient's technique and ensure they are correctly following the steps. It also provides an opportunity to correct any mistakes and reinforce proper technique, ensuring the patient is confident and competent in administering the medication.

Think of learning to drive a car. It's not enough to just read about it or watch someone else; you need to get behind the wheel and demonstrate your ability to drive safely and correctly.

Effective patient education involves not only providing information but also ensuring that the patient can apply that information correctly. The teach-back method is a key strategy in patient education because it:

1. Confirms Understanding: Directly shows whether the patient has understood the instructions.
2. Reinforces Learning: Provides an opportunity to reinforce proper technique and clarify any misunderstandings.
3. Builds Confidence: Helps the patient feel more confident in their ability to perform the procedure correctly.

By using this approach, Nurse Allen can be confident that the patient knows how to administer the ear medication properly, thereby reducing the risk of improper use and potential complications.

 

✘Incorrect answer options:

Inquire whether the patient has prior experience using ear drops. While this information can be useful, it does not confirm that the patient understands and can correctly perform the current procedure as taught.

Request the patient to paraphrase the instructions provided. Paraphrasing ensures that the patient has listened and understood the instructions but does not confirm that they can perform the procedure correctly.

Show the procedure to the patient again, encouraging any questions. Demonstrating the procedure and encouraging questions is important for teaching, but it does not confirm that the patient can perform the procedure independently.

 

References

• Bastable, S. B. (2019). Health Professional as Educator: Principles of Teaching and Learning. Jones & Bartlett Learning.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Body hair as a physical barrier. Body hair acts as a natural defense mechanism by serving as a physical barrier that helps prevent pathogens from reaching the skin. Hair, especially in areas like the nostrils, eyelashes, and eyebrows, can trap dust, microbes, and other foreign particles, preventing them from entering the body. Additionally, body hair can assist in regulating body temperature and protecting the skin from external damage, contributing to overall skin integrity and immune defense.

Think of body hair as a filter on an air conditioner. The filter traps dust and particles, preventing them from entering the system and causing problems. Similarly, body hair traps particles to keep them from entering the body.

The body's immune system includes several layers of defense mechanisms:

1. Physical Barriers: Skin and mucous membranes act as the first line of defense.
2. Chemical Barriers: Secretions like saliva, tears, and stomach acid contain enzymes that destroy pathogens.
3. Biological Barriers: Normal flora, or beneficial bacteria, compete with pathogens for nutrients and space.

Body hair falls under the category of physical barriers, working alongside other defenses to protect the body from infections.

 

✘Incorrect answer options:

Yawning to increase oxygen intake. Yawning is primarily a physiological response to tiredness or boredom and is not directly related to infection prevention. It helps increase oxygen intake and improve alertness but does not serve as a defense mechanism against pathogens.

Hiccupping to clear the respiratory tract. Hiccupping is an involuntary spasm of the diaphragm and is not a mechanism for clearing the respiratory tract or preventing infection. It is usually a temporary and harmless occurrence without a direct role in the body's defense system.

Rapid eye movements to distribute tears. Rapid eye movements occur during sleep (REM sleep) and are part of the sleep cycle rather than an infection prevention mechanism. While tears contain lysozymes that help kill bacteria and protect the eyes, rapid eye movements themselves do not contribute to this process.

 

References

• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

30 seconds. The recommended duration for hand washing after routine patient contact is at least 20 seconds. However, if the choices are limited to the options provided, 30 seconds would be the closest correct answer and ensures thorough cleaning. During this time, it is essential to cover all parts of the hands, including between the fingers and under the nails. The Centers for Disease Control and Prevention (CDC) advises that scrubbing for at least 20 seconds is adequate to effectively remove germs and reduce the risk of infection transmission. By choosing 30 seconds, Nurse Evans is ensuring that the staff errs on the side of caution, promoting more comprehensive hand hygiene practices.

Think of washing your hands like cleaning a dirty dish. If you rush the job, some residue might remain, but if you take your time and scrub thoroughly, the dish will be clean and safe to use.

Hand hygiene is a fundamental practice in preventing healthcare-associated infections (HAIs). The CDC outlines the following steps for effective hand washing:

1. Wet hands with clean, running water (warm or cold), turn off the tap, and apply soap.
2. Lather hands by rubbing them together with the soap, ensuring to cover all surfaces.
3. Scrub hands for at least 20 seconds. Need a timer? Hum the "Happy Birthday" song from beginning to end twice.
4. Rinse hands well under clean, running water.
5. Dry hands using a clean towel or air dry them.

Understanding and consistently applying these steps help reduce the spread of pathogens and protect both healthcare providers and patients.

 

✘Incorrect answer options:

One minute. While washing hands for one minute can be effective, it is not necessary for routine hand washing. This duration might be recommended in situations involving heavy contamination, but for routine patient contact, 20 seconds is sufficient.

Two minutes. Washing hands for two minutes is excessive for routine hand hygiene and can be impractical in a busy healthcare setting. This extended duration is not necessary to achieve effective germ removal.

Three minutes. Three minutes of hand washing is far beyond what is required for routine hand hygiene and would be impractical for regular practice. It is not supported by current guidelines for effective hand hygiene.

 

References

• Centers for Disease Control and Prevention. (2020). Handwashing: Clean Hands Save Lives. Retrieved from https://www.cdc.gov/handwashing/index.html.
• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.

EXPLANATION

 

✔Correct answer:

Obvious bleeding at the site of the insertion. Obvious bleeding at the site of IV insertion is not a typical symptom of phlebitis. Phlebitis refers to inflammation of the vein, usually caused by irritation from the IV catheter or the infused solution. Common symptoms of phlebitis include pain or discomfort at the IV site, swelling, warmth, and the presence of a reddish streak extending from the site, indicating inflammation and possible infection.

Think of phlebitis like a localized reaction to a splinter. The area around the splinter can become red, swollen, and warm, and there might be a red line tracking away from the site, but you wouldn't expect to see significant bleeding unless there was additional trauma.

Recognizing the signs of phlebitis is essential for prompt intervention and prevention of complications. Typical symptoms include:

1. Pain or discomfort: Often the first indication that something is wrong.
2. Swelling: Caused by inflammation and fluid accumulation.
3. Warmth: Due to increased blood flow and inflammation.
4. Red streak: Sign of inflammation spreading along the vein.

If phlebitis is suspected, the IV should be discontinued immediately, and appropriate treatment, such as applying a warm compress and monitoring for signs of infection, should be initiated.

 

✘Incorrect answer options:

Experiencing discomfort or pain at the site where the IV was inserted. Pain or discomfort at the IV site is a common symptom of phlebitis.

Swelling and a warm feeling at the site where the IV was inserted. Swelling and warmth are typical symptoms of phlebitis.

The presence of a reddish streak moving away from the site of the IV. A reddish streak is a common sign of inflammation extending along the vein and is typical of phlebitis.

 

References

• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2017). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Prevent the growth of microorganisms. The main goal of increasing urine acidity through diet is to prevent the growth of microorganisms. Acidic urine creates an environment that is less favorable for the growth of bacteria and other pathogens, thereby helping to prevent urinary tract infections (UTIs). Certain dietary modifications, such as consuming cranberry juice or vitamin C, can help acidify the urine and enhance its antibacterial properties.

Think of increasing urine acidity like adding lemon juice to water to prevent bacterial growth. The acidic environment helps to keep the water cleaner, similar to how acidic urine helps to reduce the likelihood of bacterial infections.

Urine pH can influence the risk of urinary tract infections. Key points include:

1. Urine Acidity: Lowering the pH of urine can inhibit bacterial growth, reducing the risk of UTIs.
2. Dietary Modifications: Foods and drinks that help acidify urine include cranberry juice, citrus fruits, and foods high in vitamin C.
3. Preventive Health: Maintaining acidic urine is one of several strategies to prevent recurrent UTIs, along with adequate hydration and proper hygiene.

 

✘Incorrect answer options:

Reduce burning sensations during urination. While acidic urine might indirectly help with this by preventing infections that cause burning, it is not the primary goal of increasing urine acidity.

Alter the color of the urine. The color of urine can change due to various factors, but increasing acidity is not primarily aimed at altering urine color.

Modify the urine’s concentration. Urine concentration is more influenced by fluid intake and kidney function. Increasing acidity does not significantly change the concentration of urine.

 

References

• Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis, MO: Elsevier.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2017). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Urine retention, bladder distention, and infection. Immobility can lead to impaired bladder elimination, resulting in urine retention, bladder distention, and infection. When a patient is immobile, the lack of movement can affect bladder function, causing incomplete emptying of the bladder. This can result in urine retention, which in turn can lead to bladder distention. Stagnant urine provides a favorable environment for bacterial growth, increasing the risk of urinary tract infections (UTIs).

Imagine a stagnant pond. Without proper flow and movement, the water becomes a breeding ground for bacteria. Similarly, urine that is not properly eliminated from the bladder can become stagnant and lead to infections.

Understanding the effects of immobility on urinary function is crucial for preventing complications. Key points include:

1. Urine Retention: Immobility can affect bladder emptying, leading to retention of urine.
2. Bladder Distention: Prolonged urine retention can cause the bladder to stretch and distend, leading to discomfort and potential damage.
3. Risk of Infection: Stagnant urine in a distended bladder provides an environment conducive to bacterial growth, increasing the risk of UTIs.

 

✘Incorrect answer options:

Increased urine acidity and relaxation of the perineal muscles, causing incontinence. Immobility does not typically lead to increased urine acidity or relaxation of the perineal muscles. Incontinence due to immobility is more often related to other factors such as weakened pelvic muscles or neurological issues.

Diuresis, natriuresis, and decreased urine specific gravity. Diuresis and natriuresis refer to increased urine production and sodium excretion, respectively, which are not common complications of immobility. Decreased urine specific gravity indicates dilute urine, which is also not typical in immobile patients who are at risk of urine retention.

Decreased calcium and phosphate levels in the urine. Immobility can actually lead to increased calcium levels in the urine (hypercalciuria) due to bone demineralization, not decreased levels of calcium and phosphate.

 

References

• Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis, MO: Elsevier.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2017). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

There are no contraindications for this test. The statement "There are no contraindications for this test" is false. While chest X-rays are generally safe and widely used, there are certain contraindications and considerations. For example, pregnant women are usually advised to avoid X-rays unless absolutely necessary due to the potential risk of radiation exposure to the fetus. Additionally, patients with certain medical conditions or those who have recently had other types of imaging that involve contrast agents may need special considerations.

Think of chest X-rays like taking a photograph. While it's generally safe, there are situations where you might need to be careful, like not taking flash photos around someone with epilepsy. Similarly, X-rays are safe but need caution in certain cases like pregnancy.

Understanding the indications and contraindications of diagnostic imaging procedures is essential for safe and effective patient care. Key considerations for chest X-rays include:

1. Radiation Exposure: While the amount of radiation is low, cumulative exposure can be a concern, particularly for pregnant women and young children.
2. Patient Preparation: Removing metallic objects to avoid interference with the image quality.
3. Consent and Safety: While chest X-rays typically do not require signed consent forms, informed consent is a standard practice to ensure patients understand the procedure and its risks.

 

✘Incorrect answer options:

Patients must remove all jewelry, metallic objects, and buttons above the waist before the procedure. This statement is true. Metal objects can obstruct the X-ray image, so patients are asked to remove them to ensure a clear and accurate image.

A signed consent form is not necessary for this procedure. This statement is true. Chest X-rays are considered routine procedures and do not typically require a signed consent form, although informed consent should always be obtained.

Patients are permitted to eat, drink, and take medications before this test. This statement is true. There are no restrictions on eating, drinking, or taking medications before a chest X-ray, making it a convenient diagnostic tool.

 

References

• Bontrager, K. L., & Lampignano, J. P. (2018). Textbook of Radiographic Positioning and Related Anatomy. St. Louis, MO: Elsevier.
• Ballinger, P. W., & Frank, E. D. (2016). Merrill's Atlas of Radiographic Positioning and Procedures. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

The use of soap or detergent for breaking down germs. Effective hand washing primarily relies on the use of soap or detergent. Soap works by breaking down the oils and dirt on the skin, which often harbor microorganisms, including germs and bacteria. The mechanical action of scrubbing hands together and the chemical properties of soap lift these contaminants off the skin, allowing them to be rinsed away with water. While water temperature can enhance the comfort and effectiveness of hand washing, it is the soap that plays a critical role in breaking down and removing germs.

Think of soap as a special cleaner for a greasy pan. Water alone won't remove the grease effectively, but when you use soap, it breaks down the grease, making it easy to wash away.

The Centers for Disease Control and Prevention (CDC) recommends the following steps for effective hand washing:

1. Wet hands with clean, running water (warm or cold), turn off the tap, and apply soap.
2. Lather hands by rubbing them together with the soap, covering all surfaces including the backs of hands, between fingers, and under nails.
3. Scrub hands for at least 20 seconds.
4. Rinse hands well under clean, running water.
5. Dry hands using a clean towel or air dry them.

Proper hand washing is a fundamental practice in infection control to prevent the spread of infectious diseases. Understanding and adhering to these steps are crucial for healthcare professionals in protecting themselves and their patients.

 

✘Incorrect answer options:

Utilizing hot water to kill bacteria. While hot water may provide comfort and help in dissolving soap more effectively, it is not the primary factor in killing bacteria. Extremely hot water, hot enough to kill bacteria, would also be harmful to the skin and is impractical for hand washing. The soap and mechanical action are the critical components.

Applying a disinfectant to alter surface properties. Disinfectants are used on surfaces to kill or inhibit microorganisms, but for routine hand washing, soap and water are adequate and recommended. Hand sanitizers can be used when soap and water are not available, but they are not substitutes for thorough hand washing with soap.

All of these methods combined. This option is incorrect because it includes the use of hot water and disinfectants, which are not necessary for effective hand washing. The key element is the use of soap or detergent along with proper technique and duration.

 

References

• Centers for Disease Control and Prevention. (2020). Handwashing: Clean Hands Save Lives. Retrieved from https://www.cdc.gov/handwashing/index.html.
• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.

EXPLANATION

 

✔Correct answer:

Inserting a urinary catheter. Inserting a urinary catheter always necessitates surgical asepsis (sterile technique). This is because the procedure involves entering a sterile part of the body—the urinary tract—which is normally free of microorganisms. Using sterile technique helps to prevent introducing pathogens that could cause a urinary tract infection (UTI). Surgical asepsis involves meticulous cleaning, using sterile equipment and supplies, and maintaining a sterile field to ensure no contamination occurs during the procedure.

Think of inserting a urinary catheter like performing a delicate operation inside a clean, sealed room. You must wear sterile gloves, use sterile tools, and ensure no outside contaminants enter the room to keep everything as clean as possible.

Surgical asepsis, or sterile technique, is used in procedures that invade sterile body areas or break the skin. It is critical in preventing infections and ensuring patient safety. Key components include:

1. Sterilizing all instruments and materials used in the procedure.
2. Maintaining a sterile field and environment.
3. Using sterile gloves, gowns, and drapes.
4. Proper hand hygiene and aseptic technique by the healthcare provider.

In the case of urinary catheterization, sterile technique is essential to prevent UTIs, which are a common complication in healthcare settings.

 

✘Incorrect answer options:

Administering conjugated estrogen vaginally. Administering medication vaginally generally requires clean technique rather than sterile technique. The vaginal canal is not a sterile environment, and using clean gloves and ensuring clean hands is usually sufficient.

Placing a nasogastric tube. While aseptic technique is necessary to minimize the risk of infection, placing a nasogastric tube does not require the same level of sterility as surgical asepsis. Clean gloves and maintaining a clean environment are adequate.

Irrigating a colostomy. Colostomy irrigation also requires clean technique rather than sterile technique. The procedure involves areas that are not sterile, and using clean supplies and gloves is appropriate.

 

References

• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Conducting blood typing and cross-matching. Blood typing and cross-matching are essential tests before administering a blood transfusion. Blood typing determines the patient's ABO and Rh blood groups, ensuring compatibility with the donor blood. Cross-matching involves mixing a small sample of the patient's blood with the donor blood to check for any adverse reactions. This process is crucial to prevent transfusion reactions, which can be life-threatening. Ensuring that the donor blood is compatible with the patient's blood type and cross-match is a standard and vital safety measure in transfusion medicine.

Think of blood typing and cross-matching like checking a lock and key before using it. If the key (donor blood) doesn't fit the lock (patient's blood), it won't work and could cause problems. Ensuring they match prevents issues.

Blood transfusions carry the risk of adverse reactions if the donor and recipient blood types are not compatible. The primary goals of blood typing and cross-matching are to:

1. Identify the patient's blood type (ABO and Rh): This ensures that the patient receives compatible blood.
2. Detect any antibodies in the patient's blood: This helps to avoid potential reactions with donor blood.
3. Ensure compatibility: Cross-matching confirms that the donor blood is safe for transfusion into the patient.

These steps are vital for the safety and effectiveness of blood transfusions.

 

✘Incorrect answer options:

Testing prothrombin time and overall coagulation. These tests assess the patient's clotting function and are important in managing bleeding disorders but are not specific to ensuring compatibility for blood transfusions.

Evaluating bleeding time and clotting time. These tests also evaluate the patient’s hemostatic function and are used in different contexts, such as diagnosing clotting disorders, but they are not directly related to ensuring safe blood transfusions.

Performing a complete blood count (CBC) and checking electrolyte levels. A CBC provides important information about the patient’s overall health and the need for a transfusion but does not ensure the compatibility of donor blood with the recipient’s blood.

 

References

• American Association of Blood Banks (AABB). (2017). Standards for Blood Banks and Transfusion Services. Bethesda, MD: AABB.
• Harmening, D. M. (2019). Modern Blood Banking & Transfusion Practices. Philadelphia, PA: F.A. Davis Company.

EXPLANATION

 

✔Correct answer:

White potatoes. White potatoes are not a good source of vitamin A. Vitamin A is primarily found in foods that contain beta-carotene (which the body converts to vitamin A) or in animal products that contain retinoids. Good sources of vitamin A include orange and yellow vegetables and fruits, such as carrots and apricots, as well as animal products like egg yolks. White potatoes lack significant amounts of beta-carotene or retinoids, making them a poor source of vitamin A.

Think of vitamin A like a special dye that gives foods their vibrant colors. Foods that are bright orange or yellow, like carrots and apricots, are rich in this dye. White potatoes, being pale, do not contain much of this special dye (vitamin A).

Understanding the sources of essential vitamins is crucial for nutritional counseling. Key points include:

1. Beta-Carotene: Found in brightly colored fruits and vegetables like carrots, sweet potatoes, and apricots.
2. Retinoids: Found in animal products such as egg yolks, liver, and dairy products.
3. Dietary Recommendations: Including a variety of these sources in the diet helps ensure adequate intake of vitamin A, which is important for vision, immune function, and skin health.

 

✘Incorrect answer options:

Carrots. Carrots are an excellent source of beta-carotene, which the body converts into vitamin A.

Apricots. Apricots contain beta-carotene and are a good source of vitamin A.

Egg yolks. Egg yolks contain retinoids and are a good source of vitamin A.

 

References

• Gropper, S. S., Smith, J. L., & Carr, T. P. (2017). Advanced Nutrition and Human Metabolism. Boston, MA: Cengage Learning.
• Mahan, L. K., Escott-Stump, S., & Raymond, J. L. (2016). Krause's Food & the Nutrition Care Process. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

It can accommodate only up to 1 ml of medication. The mid-deltoid site is seldom used for intramuscular (I.M.) injections because it can accommodate only up to 1 ml of medication. The deltoid muscle is smaller compared to other muscles used for I.M. injections, such as the vastus lateralis or the gluteus medius. Administering more than 1 ml in this site increases the risk of muscle damage, irritation, and pain.

Think of the deltoid muscle like a small cup. If you try to pour too much liquid into it, the cup overflows and makes a mess. Similarly, injecting more than 1 ml of medication into the deltoid can lead to complications.

Intramuscular injections require the selection of an appropriate site to ensure effective delivery of the medication and minimize complications. Key considerations include:

1. Muscle size and volume capacity: The deltoid muscle is suitable for smaller volumes (up to 1 ml) due to its limited size.
2. Proximity to nerves and blood vessels: The deltoid site is close to the radial nerve and the brachial artery, so care must be taken to avoid these structures.
3. Patient comfort and accessibility: While the deltoid site is easily accessible, it is best suited for small-volume injections and vaccines.

 

✘Incorrect answer options:

It bruises too easily. Bruising can occur at any injection site, and while the deltoid might be more prone to discomfort due to its frequent use, this is not the primary reason it is less favored for larger volume injections.

It can only be accessed when the patient is lying down. The deltoid site can be accessed whether the patient is sitting, standing, or lying down, making it convenient for many situations.

It does not absorb parenteral medications well. The deltoid muscle can effectively absorb medications, but the volume capacity is the limiting factor, not absorption efficacy.

 

References

• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.
• Lehne, R. A. (2013). Pharmacology for Nursing Care. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Gauge 26. The most appropriate needle gauge for intradermal injections is 26G. Intradermal injections are administered into the dermal layer of the skin, which requires a very fine needle to minimize discomfort and ensure precise delivery of the substance. A 26-gauge needle is thin enough to achieve these goals while being sturdy enough to handle the injection process.

Imagine using a very fine sewing needle to make a precise stitch on delicate fabric. A thicker needle might tear the fabric or leave a noticeable hole, but a fine needle allows you to make a delicate, accurate stitch without damaging the material. Similarly, a fine gauge needle (26G) is ideal for intradermal injections to ensure precision and minimize discomfort.

Intradermal injections are commonly used for allergy testing, tuberculosis screening, and certain vaccines. The key aspects of selecting the appropriate needle gauge include:

1. Needle Gauge (G): The gauge indicates the thickness of the needle. A higher gauge number means a thinner needle. For intradermal injections, a thin needle (26G or higher) is necessary to ensure precision and minimize tissue trauma.
2. Injection Technique: Proper technique involves inserting the needle at a shallow angle (usually 5 to 15 degrees) just under the skin's surface to create a small wheal or blister.
3. Patient Comfort: Using a fine gauge needle helps reduce pain and discomfort for the patient during the injection.

 

✘Incorrect answer options:

Gauge 20. A 20-gauge needle is much too thick for intradermal injections. It is typically used for intramuscular or intravenous injections where a larger bore is needed.

Gauge 22. A 22-gauge needle is also too thick for intradermal injections. It is more suitable for intramuscular or subcutaneous injections.

Gauge 25. While a 25-gauge needle is thinner, it is still not as fine as typically required for intradermal injections. For maximum accuracy and minimal discomfort, a higher gauge (e.g., 26G or finer) is preferred.

 

References

• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.
• Centers for Disease Control and Prevention (CDC). (2020). General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). Retrieved from https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs.html.

EXPLANATION

 

✔Correct answer:

Vigorously rubbing the site after injection to enhance absorption. Vigorously rubbing the site after an injection is not a correct intervention for the Z-track method. The Z-track method is designed to minimize irritation and prevent the medication from leaking into subcutaneous tissue. Rubbing the injection site can cause irritation, increase the risk of bruising, and potentially allow the medication to move into the subcutaneous tissue, defeating the purpose of the Z-track technique.

Think of the Z-track method like sealing a leak-proof bag by carefully closing it along a specific path to prevent spills. Rubbing the injection site would be like shaking the sealed bag, potentially causing leaks and defeats the purpose of the careful sealing.

The Z-track method is used to administer intramuscular injections in a way that minimizes discomfort and prevents medication from leaking into subcutaneous tissue. Key steps include:

1. Cleansing the injection site with alcohol: This is a standard practice to reduce the risk of infection.
2. Utilizing a needle that is at least 1 inch long: This ensures the medication is delivered deep into the muscle tissue.
3. Aspirating for blood before administering the injection: This checks for accidental needle placement in a blood vessel.
4. Avoiding vigorous rubbing of the site after injection: Instead, applying gentle pressure with a cotton ball or gauze is recommended.

 

✘Incorrect answer options:

Cleansing the injection site with alcohol. This is correct and necessary to prevent infection.

Utilizing a needle that is at least 1 inch long. This is correct to ensure the medication reaches the muscle tissue and not the subcutaneous layer.

Aspirating for blood before administering the injection. This is correct to ensure that the needle is not in a blood vessel, although recent guidelines suggest that aspiration may not be necessary for all intramuscular injections.

 

References

• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.
• Lehne, R. A. (2013). Pharmacology for Nursing Care. St. Louis, MO: Elsevier.

EXPLANATION

 

✔Correct answer:

Positioning a sterile object at the boundary of the sterile field. Positioning a sterile object at the boundary of the sterile field constitutes a breach in sterile technique because it increases the risk of contamination. The boundary of a sterile field is considered a potential zone of contamination. To maintain sterility, all sterile items should be placed well within the designated sterile area, ensuring there is no risk of them coming into contact with non-sterile surfaces or objects. This practice helps to maintain the integrity of the sterile field and prevents infections.

Imagine a clean picnic blanket laid out on the grass. If you place food items right at the edge of the blanket, there's a higher chance they might touch the grass and get dirty. Keeping the food well inside the blanket area helps ensure it stays clean.

Foundational Principles: Maintaining a sterile field involves several key principles, including:

1. Only sterile items may be placed in a sterile field.
2. The edges of a sterile field or container are considered contaminated.
3. Movement around the sterile field should not compromise its sterility.
4. If sterility is ever in doubt, the field is considered contaminated and must be reestablished.

Adhering to these principles is crucial for preventing infection and ensuring patient safety during procedures requiring sterility.

 

✘Incorrect answer options:

Handling a sterile item with sterile forceps instead of sterile gloves. Using sterile forceps to handle sterile items is an acceptable practice in maintaining sterility, provided the forceps themselves are sterile. This method helps avoid direct hand contact and is not a breach of sterile technique.

Contacting the outer wrapper of sterilized material without wearing sterile gloves. The outer wrapper of sterilized materials is not considered sterile, so it can be handled without sterile gloves. The key is to ensure that the inner contents remain sterile when transferred to the sterile field.

Discarding a small amount of solution before pouring the rest into a sterile container. This practice, known as "lipping," is done to remove any contaminants that may be present at the lip of the container. It is a standard procedure and does not constitute a breach of sterile technique.

 

References

• Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia, PA: Wolters Kluwer Health.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing. St. Louis, MO: Elsevier.