Nursing Elites

1. A client is admitted to isolation with active tuberculosis. What infection control measures should the nurse implement?

• A. Initiate protective environment precautions.
• B. Use droplet precautions only.
• C. Ensure a positive pressure environment in the room.
• D. Implement negative pressure and contact precautions.

Correct answer: D

Rationale: When caring for a client with active tuberculosis, it is crucial to implement negative pressure rooms and contact precautions to prevent the spread of infection. Choice A, initiating protective environment precautions, is incorrect as this is not the recommended approach for tuberculosis. Choice B, using droplet precautions only, is insufficient as tuberculosis requires additional precautions. Choice C, ensuring a positive pressure environment in the room, is incorrect because negative pressure rooms are necessary to contain airborne pathogens like tuberculosis. Therefore, the most appropriate measures include implementing negative pressure rooms and contact precautions.

2. A client with chronic obstructive pulmonary disease (COPD) is being discharged home. What should the nurse include in the discharge teaching?

• A. Limit fluid intake to prevent lung congestion
• B. Avoid all physical activity to conserve energy
• C. Perform pursed-lip breathing during activities
• D. Increase oxygen flow rate if shortness of breath occurs

Correct answer: C

Rationale: The correct answer is C. Pursed-lip breathing helps control breathing and improves oxygen exchange in clients with COPD. It can ease shortness of breath during activities and should be included in discharge teaching to manage symptoms. Option A is incorrect as adequate fluid intake is important for thinning mucus in COPD. Option B is wrong as physical activity, as tolerated, is beneficial for COPD patients. Option D is also incorrect because changing oxygen flow rate without healthcare provider guidance can be dangerous.

3. The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention?

• A. A 17-year-old client with schizophrenia who is pacing the hallways
• B. An 18-year-old client with antisocial behavior who is being yelled at by other clients
• C. A 16-year-old client with depression who refuses to eat meals
• D. A 15-year-old client with anxiety who is quietly reading in a corner

Correct answer: B

Rationale: The client with antisocial behavior being yelled at by peers may escalate the situation, potentially leading to violence or self-harm. Addressing the situation quickly helps prevent harm and de-escalates the conflict. Choices A, C, and D do not present immediate risks that require urgent intervention compared to the potential danger of a conflict escalating to violence with the client exhibiting antisocial behavior.

4. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

• A. An 8-year-old living in a housing project.
• B. A 2-year-old playing on aging playground equipment.
• C. An adolescent working in a paint factory.
• D. A 10-year-old with Type 1 diabetes.

Correct answer: B

Rationale: The correct answer is B. Young children, like the 2-year-old playing on aging playground equipment, are more susceptible to lead poisoning from environmental sources due to their behaviors like hand-to-mouth contact and exploratory behaviors. Choices A, C, and D are less likely to be at high risk for lead poisoning compared to young children due to differences in exposure levels and behaviors related to potential sources of lead contamination.

5. A client recovering from a stroke is demonstrating slurred speech. What action should the nurse take?

• A. Consult the healthcare provider to order speech therapy.
• B. Administer a dose of aspirin to prevent further neurological damage.
• C. Encourage the client to use communication aids, such as writing.
• D. Encourage the client to eat soft foods to avoid choking.

Correct answer: C

Rationale: The correct action for a client recovering from a stroke demonstrating slurred speech is to encourage the client to use communication aids, such as writing. This intervention can help the client effectively communicate while working on regaining speech abilities. Consulting the healthcare provider to order speech therapy (choice A) is a valid option, but immediate encouragement of using communication aids is beneficial. Administering aspirin (choice B) without healthcare provider orders is not recommended. Encouraging the client to eat soft foods (choice D) is important for preventing aspiration but doesn't directly address the communication issue.

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