Nursing Elites

1. A 20-year-old client has an infected leg wound from a motorcycle accident and has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:

• A. Visitors must wear a mask and a gown
• B. There are no special requirements for visitors of clients on contact precautions
• C. Visitors should wash their hands before and after touching the client
• D. Visitors -

Correct answer: C

Rationale: The correct answer is C: 'Visitors should wash their hands before and after touching the client.' When a client is on contact precautions, it is essential for visitors to practice good hand hygiene to prevent the spread of infection. While wearing a mask and a gown might be necessary for healthcare providers, it is not typically required for visitors. Option B is incorrect because there are indeed special requirements for visitors on contact precautions, including practicing good hand hygiene. Option D is incomplete and does not provide any guidance on infection prevention measures.

2. When reassigned to the emergency department, a nurse should understand that gastric lavage is a priority in which situation?

• A. An infant who has been identified to have botulism
• B. A toddler who ate a number of ibuprofen tablets
• C. A preschooler who swallowed powdered plant food
• D. A school-aged child who took a handful of vitamins

Correct answer: A

Rationale: The correct answer is A because gastric lavage is a priority for infants with botulism to remove toxins from the stomach. Botulism is a serious condition caused by a toxin produced by Clostridium botulinum bacteria. Gastric lavage helps in removing the toxin from the stomach. Choice B is incorrect because gastric lavage is not typically indicated for ibuprofen ingestion. Choice C is incorrect because gastric lavage is not the first-line treatment for ingesting powdered plant food. Choice D is incorrect because gastric lavage is not routinely performed for vitamin ingestion.

3. When assessing constipation in elders, which action should be the nurse's priority?

• A. Obtain a complete blood count
• B. Obtain a health and dietary history
• C. Refer to a provider for a physical examination
• D. Measure height and weight

Correct answer: B

Rationale: The correct answer is to obtain a health and dietary history when assessing constipation in elders. This action is crucial as it helps the nurse identify potential causes and contributing factors to constipation in elderly clients. Obtaining a complete blood count (choice A) may be necessary at some point, but it is not the priority in this situation. Referring to a provider for a physical examination (choice C) and measuring height and weight (choice D) are important but are not the priority actions when assessing constipation.

4. A nurse is reinforcing teaching with the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include in the teaching?

• A. Sliced bananas
• B. Raw celery
• C. Peanut butter
• D. Marshmallows

Correct answer: A

Rationale: The correct answer is A: Sliced bananas. Sliced bananas are a healthy and safe snack option for toddlers as they provide essential nutrients and are easy to chew. Bananas are a good source of potassium and fiber. Choice B, raw celery, may pose a choking hazard for toddlers due to its stringy texture. Choice C, peanut butter, can also be a choking hazard and may not be suitable for all toddlers due to potential allergies. Choice D, marshmallows, are high in sugar and low in nutrients, making them an unhealthy choice for toddler snacks.

5. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication:

• A. Can predispose to dysrhythmias
• B. May lead to oliguria
• C. May cause irritability and anxiety
• D. Sometimes alters consciousness

Correct answer: A

Rationale: The correct answer is A: Hypokalemia increases the risk of dysrhythmias when taking digoxin, making potassium intake crucial. Digoxin toxicity is more likely in patients with low potassium levels, leading to an increased risk of dysrhythmias. Choices B, C, and D are incorrect because hypokalemia in combination with digoxin is primarily associated with dysrhythmias rather than oliguria, irritability, anxiety, or alteration of consciousness.

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