During the surgical procedure, the nurse notices a break in sterile technique by a member of the surgical team. What should the nurse do?

Correct Answer: C

Rationale: In this situation, it is crucial for the nurse to inform the surgeon immediately and request corrective action. Maintaining a sterile field during surgical procedures is essential to prevent infections and ensure patient safety. Any break in sterile technique should be addressed promptly to prevent any potential harm to the patient. By informing the surgeon immediately, corrective action can be taken promptly to maintain the sterility of the surgical field and minimize the risk of complications. Reporting the incident to the surgeon also allows for immediate intervention and re-education of the team member involved in the break in sterile technique.

Correct Answer: C

Rationale: Choosing option C, asking the patient about their cultural beliefs and preferences related to pain, demonstrates cultural competence in pain assessment. Pain experiences can vary greatly across different cultures, and a patient's cultural background can influence how they perceive and express pain. By inquiring about the patient's cultural beliefs and preferences, the nurse can gain a better understanding of the patient's perspective on pain. This information is crucial for providing individualized and culturally sensitive pain management interventions. It also shows respect for the patient's unique cultural background and helps build a trusting and collaborative relationship between the nurse and the patient.

Correct Answer: B

Rationale: When a nurse is delegating tasks to a nursing assistant, the principle that should guide the nurse's delegation decisions is assigning tasks based on the assistant's level of experience (Option B). It is essential to take into consideration the skills, competencies, and experience level of the nursing assistant to ensure that the tasks delegated are suitable for them to perform safely and effectively. Delegating tasks beyond the assistant's level of experience may result in errors, inefficiencies, or compromised patient care. Therefore, matching tasks with the assistant's experience level is crucial in successful delegation and providing quality patient care.

Correct Answer: B

Rationale: The correct action for the nurse to ensure proper insertion technique during a urinary catheterization is to use aseptic technique and sterile equipment. This is crucial in preventing infections and ensuring patient safety. Aseptic technique involves maintaining cleanliness and preventing the introduction of harmful microorganisms during invasive procedures like catheterization. Using sterile equipment helps minimize the risk of introducing bacteria into the urinary tract, which could lead to a urinary tract infection (UTI). Therefore, it is essential that the nurse follows strict infection control protocols and uses sterile equipment to maintain patient safety and well-being during the catheterization procedure.

Correct Answer: D

Rationale: When performing an intramuscular (IM) injection, the nurse should insert the needle at a 90-degree angle into the muscle. This angle helps ensure proper and deep penetration into the muscle tissue for effective administration of the medication. It also helps prevent leakage or tissue damage at the injection site. Additionally, inserting the needle at a 90-degree angle facilitates accurate delivery of the medication into the muscle where it can be absorbed properly. Therefore, selecting the correct angle for inserting the needle is critical in ensuring the success and effectiveness of the IM injection.