Nursing Elites

1. A child with newly diagnosed leukemia is receiving chemotherapy. Which would be included in his plan of care by the nurse?

• A. Place the child in a negative pressure isolation room
• B. Administer prophylactic IV antibiotics
• C. Avoid high protein food intake
• D. Teach family and visitors handwashing techniques

Correct answer: D

Rationale: The correct answer is to teach family and visitors handwashing techniques. Any client on chemotherapy should have good infection control measures in place, such as handwashing by all who they encounter. Placing the child in a negative pressure isolation room (Choice A) is not necessary unless specifically indicated for a certain condition. Administering prophylactic IV antibiotics (Choice B) may not be part of the standard care plan for a child with leukemia receiving chemotherapy. Avoiding high protein food intake (Choice C) is not directly related to infection control and may not be necessary unless there are specific dietary restrictions.

2. A nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?

• A. cold, burning, aching, and numbness
• B. burning, aching, cold, and numbness
• C. aching, cold, burning, and numbness
• D. cold, aching, burning, and numbness

Correct answer: A

Rationale: The correct order of sensations experienced with an ice water bath is cold, burning, aching, and numbness, as stated by the acronym CBAN (cold, burn, ache, numbness). Option A is the correct sequence. Choice B is incorrect as it starts with burning, which typically follows the cold sensation. Choice C is incorrect as aching is usually felt after the burning sensation. Choice D is incorrect as aching usually occurs after the burning sensation.

3. The charge nurse is observing a student nurse caring for a 4-month-old infant in isolation diagnosed with RSV. Which of the following would indicate to the charge nurse that the student nurse needs further instruction on isolation standards?

• A. Donning clean gloves each time she goes in the room.
• B. Wearing a clean mask each time she goes in the room.
• C. Labeling the door so staff will use Airborne Precautions.
• D. Wearing a gown when she goes in the room to administer medication.

Correct answer: A

Rationale: The correct answer is 'Donning clean gloves each time she goes in the room.' Sterile gloves are not necessary for standard isolation precautions; clean gloves are sufficient. The student nurse should be instructed to use clean gloves to reduce the risk of spreading infections. Wearing a clean mask each time she goes in the room is a good practice to prevent the spread of respiratory infections like RSV. Labeling the door for Airborne Precautions is appropriate for RSV. Wearing a gown when entering the room to administer medication helps prevent the transmission of infectious agents.

4. A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63mmHg, HCO3 23, and oxygenation saturation (SAO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs?

• A. tuberculosis (TB)
• B. pneumonia
• C. pleural effusion
• D. hypoxia

Correct answer: D

Rationale: A combined low PO2 and low SAO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not necessarily altered in TB or pleural effusion. In pneumonia, the PO2 and PCO2 might be low because hypoxia stimulates hyperventilation, but the best analysis in this case is hypoxia due to the combination of low PO2 and low SAO2.

5. A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?

• A. Ask the nursing assistant to complete emptying the catheter bag and assess the new admission.
• B. Ask the nursing assistant to take vital signs on the new admit and begin the history until she can get there.
• C. Ask the graduate nurse on the floor to initiate the assessment process until she can get there.
• D. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

Correct answer: C

Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.

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