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. While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first?

• A. Instruct the client to perform cough and deep breathing exercises
• B. Assess the client’s vital signs and respiratory effort
• C. Administer oxygen via nasal cannula according to the PNR protocol
• D. Document assessment findings in the client’s medical record

Correct answer: B

Rationale: The correct first action for the nurse to take in this situation is to assess the client’s vital signs and respiratory effort. It is crucial to promptly detect any immediate complications or changes in the client's condition. Instructing cough and deep breathing exercises (choice A) can be considered after further assessment. Administering oxygen (choice C) should be based on assessment findings and healthcare provider's orders. While documenting the findings (choice D) is essential, it should not be the first action when a potential issue with breath sounds is detected.

3. A client who will be going to surgery states no known allergies to any medications. What is the most important nursing action for the nurse to implement next?

• A. Assess client’s knowledge of an allergic response
• B. Record 'no known drug allergies' on the preoperative checklist
• C. Flag 'no known drug allergies' on the front of the chart
• D. Assess client’s allergies to non-drug substances

Correct answer: B

Rationale: The most important action to take in this situation is to record 'no known drug allergies' on the preoperative checklist. This ensures that all healthcare staff involved in the surgery are aware of the client's stated lack of drug allergies, helping to prevent any potential adverse reactions. Assessing the client's knowledge of an allergic response (Choice A) may be valuable but is not the most crucial action at this point. Flagging 'no known drug allergies' on the front of the chart (Choice C) is less practical and visible compared to documenting it on the preoperative checklist. Assessing the client’s allergies to non-drug substances (Choice D) is not the priority in this scenario where the focus is on medications due to the upcoming surgery.

4. After 2 days of treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child’s urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement?

• A. Perform a finger stick glucose test
• B. Increase the IV fluid flow rate
• C. Review 24-hour intake and output
• D. Obtain arterial blood gases

Correct answer: A

Rationale: Lethargy and difficulty arousing may indicate hypoglycemia, which should be assessed before other actions. Performing a finger stick glucose test is crucial to evaluate the child's blood sugar levels and address hypoglycemia promptly. Increasing the IV fluid flow rate is not indicated without knowing the glucose status. Reviewing 24-hour intake and output is important but not the priority when lethargy and difficulty arousing are present. Obtaining arterial blood gases is not the primary assessment needed in this situation.

5. Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client’s plan of care?

• A. Confusion
• B. Check neuro vital signs every 4 hours.
• C. Maintain intravenous access.
• D. Keep the suture line clean and dry.

Correct answer: C

Rationale: The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.

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