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 client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all that apply)

• A. Encourage oral fluid intake of 3,000 ml/day
• B. Observe for evidence of hypokalemia
• C. Teach the client how to restrict dietary sodium
• D. Monitor PTT, PT, and INR lab values

Correct answer: B

Rationale: The correct interventions to include when a client with heart failure is being treated with diuretics for fluid volume excess are to observe for evidence of hypokalemia. Diuretics can lead to potassium loss, resulting in hypokalemia. Monitoring for this electrolyte imbalance is crucial. Encouraging oral fluid intake of 3,000 ml/day may exacerbate fluid volume excess in a client with heart failure. Teaching the client how to restrict dietary sodium is important in managing heart failure, but it is not directly related to the use of diuretics for fluid volume excess. Monitoring PTT, PT, and INR lab values is not typically associated with diuretic therapy for heart failure but rather with anticoagulant therapy.

3. When the client asks the nurse if they have ever been with someone when they died, what is the nurse’s best response?

• A. “Yes, I have. Do you have some questions about dying?”
• B. “Several times. Now, let’s get your dressing changed.”
• C. “A few times. It was peaceful and there was no pain.”
• D. “Yes, but you’re doing great. Are you concerned about dying?”

Correct answer: A

Rationale: Choice A is the best response as it acknowledges the client's question and opens the door for further discussion about dying if the client wishes to. It shows empathy and encourages the client to express any concerns they may have. Choices B and C do not directly address the client's question or offer an opportunity for him to explore his concerns. Choice D acknowledges the experience but fails to address the client's question directly and does not encourage further discussion.

4. A postpartum client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client?

• A. Take a prescribed analgesic and expose breasts to air
• B. Place warm packs on both breasts
• C. Avoid stimulation of the breasts and wear a tight bra
• D. Express a small amount of breast milk by hand

Correct answer: C

Rationale: For a postpartum client who is bottle feeding and develops breast engorgement, the best recommendation is to avoid stimulation of the breasts and wear a tight bra. This helps reduce engorgement by decreasing blood flow to the breasts. Option A is incorrect because exposing the breasts to air can further stimulate them, worsening engorgement. Option B is incorrect as warm packs can increase blood flow and exacerbate engorgement. Option D is incorrect as expressing breast milk can lead to further stimulation and increased engorgement.

5. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

• A. Working together can decrease the risk of back injury.
• B. The technique is intended to maintain straight spinal alignment.
• C. Using two or three people increases client safety.
• D. Turning instead of pulling reduces the likelihood of skin damage.

Correct answer: B

Rationale: The correct answer is B: 'The technique is intended to maintain straight spinal alignment.' Log-rolling is a technique used to move a person as a single unit to maintain the alignment of the spinal column. This is crucial to prevent spinal cord injury, especially in clients with suspected spine fractures. Choice A is incorrect because log-rolling focuses on spinal alignment, not just decreasing back injury risks. Choice C is incorrect because the number of people involved is not the primary purpose of log-rolling, which is maintaining spinal alignment. Choice D is incorrect because while turning instead of pulling may help prevent skin damage, the primary goal of log-rolling is to protect the spine, not the skin.

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