Nursing Elites

1. When admitting a client diagnosed with active tuberculosis to isolation, which infection control measures should the nurse implement?

• A. Negative pressure environment
• B. Contact precautions
• C. Droplet precautions
• D. Protective environment

Correct answer: A

Rationale: The correct answer is A: Negative pressure environment. Tuberculosis is transmitted through airborne particles, so a negative pressure room is essential to prevent the spread of the bacteria. Choice B, contact precautions, are used for infections spread by direct or indirect contact, not for tuberculosis. Choice C, droplet precautions, are for infections transmitted through respiratory droplets, not airborne particles like tuberculosis. Choice D, protective environment, is used for protecting immunocompromised patients from outside pathogens, not for preventing the spread of tuberculosis.

2. A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2 °F, and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?

• A. Occult blood in the stool
• B. Abdominal distention
• C. Elevated urine specific gravity
• D. Hyperactive bowel sounds

Correct answer: C

Rationale: Elevated urine specific gravity indicates concentrated urine, a sign of dehydration. In this scenario, the child is showing signs of dehydration with increased stool frequency, liquid consistency, fever, and vomiting. Occult blood in the stool may indicate gastrointestinal bleeding but is not a specific sign of dehydration. Abdominal distention can be seen in various conditions and is not a specific indicator of dehydration. Hyperactive bowel sounds can be present in various gastrointestinal conditions but are not directly related to dehydration.

3. A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement?

• A. Increase the intake of salty foods
• B. Administer NaCl supplements
• C. Restrict oral fluid intake
• D. Hold the client's loop diuretic

Correct answer: C

Rationale: In the scenario described, the client presents with signs of fluid overload and hyponatremia. Restricting oral fluid intake is the appropriate intervention to manage fluid overload and correct hyponatremia. Increasing the intake of salty foods (Choice A) and administering NaCl supplements (Choice B) would exacerbate the sodium imbalance. Holding the client's loop diuretic (Choice D) is not directly related to addressing the fluid overload and hyponatremia.

4. When preparing the client for a thoracentesis, which action is essential for the nurse to take?

• A. Encourage the client to cough during the procedure
• B. Ask the client to void prior to the procedure
• C. Have the client lie in the prone position
• D. Determine if chest x-rays have been completed

Correct answer: B

Rationale: The essential action for the nurse to take when preparing a client for a thoracentesis is to ask the client to void prior to the procedure. This step is crucial as it helps prevent discomfort and reduces the risk of accidental injury. Encouraging the client to cough during the procedure (Choice A) is inappropriate as it can affect the accuracy of the thoracentesis. Having the client lie in the prone position (Choice C) is incorrect; the procedure is typically performed with the client sitting upright or slightly leaning forward. While determining if chest x-rays have been completed (Choice D) is important, ensuring the client has emptied their bladder is more critical for their comfort and safety during the procedure.

5. The client enters the room of a client with Parkinson’s disease who is taking carbidopa-levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take?

• A. Demonstrate how to help the client move more efficiently
• B. Offer a PRN analgesic to reduce painful movement
• C. Affirm that the client should arise slowly from the chair
• D. Tell the UAP to assist the client in moving more quickly

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to demonstrate how to help the client move more efficiently. As the client is arising slowly from the chair, providing guidance on proper movement techniques can improve the client's mobility and safety. Offering a PRN analgesic (Choice B) is not relevant to the client's situation as there is no indication of pain. Affirming that the client should arise slowly (Choice C) does not address the need for assistance in improving movement efficiency. Instructing the UAP to assist the client in moving more quickly (Choice D) may compromise the client's safety and is not the appropriate action to take.

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