Nursing Elites

1. A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

• A. Evacuate the client
• B. Attempt to extinguish the fire
• C. Call the fire department
• D. Close the door to contain the fire

Correct answer: A

Rationale: The correct answer is to Evacuate the client (Choice A). In the event of a fire, the safety of the client is the top priority. The RACE (Rescue, Alarm, Contain, Extinguish) mnemonic is used in fire emergencies. The first step is to Rescue or Evacuate the individual from immediate danger. Attempting to extinguish the fire (Choice B) may endanger both the client and the nurse. Calling the fire department (Choice C) is important but should come after ensuring the client's safety. Closing the door to contain the fire (Choice D) is not appropriate in this scenario because the priority is to remove the client from harm's way.

2. What intervention can help prevent atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?

• A. Active and passive range of motion exercises twice a day
• B. Every 4 hours incentive spirometer
• C. Chest physiotherapy twice a day
• D. Repositioning every 2 hours around the clock

Correct answer: C

Rationale: Chest physiotherapy is essential for clients with amyotrophic lateral sclerosis (ALS) to prevent atelectasis and pneumonia. Chest physiotherapy aids in clearing secretions, maintaining lung function, and preventing respiratory complications. Active and passive range of motion exercises (Choice A) are important for maintaining joint mobility but are not directly associated with preventing atelectasis and pneumonia in ALS. Incentive spirometer use every 4 hours (Choice B) is beneficial for lung expansion and preventing atelectasis but may not be as effective as chest physiotherapy in managing secretions. Repositioning every 2 hours (Choice D) is crucial for preventing pressure ulcers but is not directly related to preventing atelectasis and pneumonia in ALS.

3. The healthcare provider is educating a client about dietary changes to prevent the recurrence of calcium oxalate kidney stones. Which food should the provider advise the client to avoid?

• A. Spinach
• B. Bananas
• C. Chicken
• D. Rice

Correct answer: A

Rationale: The correct answer is A: Spinach. Spinach is high in oxalate, a compound that can contribute to the formation of calcium oxalate kidney stones. Therefore, advising the client to avoid spinach is crucial in reducing the risk of stone recurrence. Bananas (choice B) are not high in oxalate and do not directly contribute to the formation of calcium oxalate stones, so they do not need to be avoided. Similarly, choices C and D, chicken, and rice, are not typically associated with high oxalate content, making them safe choices and do not need to be avoided specifically to prevent calcium oxalate kidney stones.

4. When should the nurse plan to collect a sputum specimen for culture and sensitivity as ordered by a client's provider?

• A. In the morning upon rising.
• B. Immediately after the client eats breakfast.
• C. Before the client goes to bed.
• D. After the client has had a drink of water.

Correct answer: A

Rationale: The correct time to collect a sputum specimen for culture and sensitivity is in the morning upon rising. This timing ensures the most concentrated sample as sputum produced overnight tends to accumulate and sit in the airways, providing a quality sample for testing. Collecting the specimen immediately after eating breakfast (choice B) may introduce food particles that could contaminate the sample. Collecting it before bed (choice C) may lead to a diluted sample due to daily activities. Collecting the specimen after having a drink of water (choice D) can also result in a diluted sample, impacting the accuracy of the test results.

5. The healthcare provider is caring for a client with tuberculosis (TB). Which type of isolation precautions should the healthcare provider implement?

• A. Droplet precautions
• B. Airborne precautions
• C. Contact precautions
• D. Standard precautions

Correct answer: B

Rationale: When caring for a client with tuberculosis (TB), airborne precautions should be implemented. Tuberculosis is spread through the air via droplet nuclei, requiring the use of airborne precautions to prevent the transmission of the infection. Droplet precautions are used for diseases spread by large respiratory droplets, such as influenza or pertussis. Contact precautions are used for diseases that spread through direct contact, such as MRSA. Standard precautions are used for all clients to prevent the transmission of infections from blood, body fluids, non-intact skin, and mucous membranes.

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