Nursing Elites

1. A client with a severe peanut allergy accidentally ingested peanut-containing food and is experiencing anaphylaxis. What is the nurse's priority action?

• A. Administer an epinephrine injection
• B. Call for immediate medical help
• C. Monitor airway, breathing, and circulation
• D. All of the above

Correct answer: A

Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.

2. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape to anchor the shield most effectively?

• A. Place tape from the cheek to the forehead
• B. Secure tape from the nose to the ear
• C. Attach tape from the lower eyelid to the upper forehead
• D. Use circular bandaging around the head

Correct answer: C

Rationale: The correct way to apply tape to anchor an eye shield effectively is to attach the tape from the lower eyelid to the upper forehead. This method provides stability for the shield without putting pressure on the eye itself, thus helping to protect the eye. Choices A, B, and D are incorrect because taping from the cheek to the forehead, securing tape from the nose to the ear, or using circular bandaging around the head may not provide the necessary stability and protection required for the eye shield.

3. The nurse is preparing to administer a tuberculin skin test (TST). Which area of the body is the preferred site for this injection?

• A. Deltoid muscle
• B. Inner forearm
• C. Abdomen
• D. Thigh

Correct answer: B

Rationale: The inner forearm is the preferred site for administering a tuberculin skin test (TST) due to its easy accessibility, minimal hair interference, and good visibility of the injection site, allowing for accurate interpretation of the test results. The deltoid muscle, abdomen, and thigh are not preferred sites for a TST as they may not provide the optimal conditions required for the test. The deltoid muscle is commonly used for intramuscular injections, the abdomen may have varying subcutaneous fat thickness affecting the test, and the thigh may not provide the necessary visibility for accurate reading.

4. Which intervention is most effective in preventing the spread of infection in a healthcare setting?

• A. Wearing gloves
• B. Using hand sanitizer
• C. Practicing hand hygiene
• D. Disinfecting surfaces

Correct answer: C

Rationale: Practicing hand hygiene is the most effective measure to prevent the spread of infection in healthcare settings. While wearing gloves, using hand sanitizer, and disinfecting surfaces are important infection control measures, they are not as effective as proper hand hygiene. Hand hygiene, including handwashing with soap and water or using alcohol-based hand sanitizers, is crucial in preventing the transmission of pathogens from one person to another, making it the best choice among the options provided. Wearing gloves primarily protects the wearer and is not a substitute for hand hygiene. Using hand sanitizer is helpful but may not be as effective as proper handwashing. Disinfecting surfaces is important but does not address the direct transmission of pathogens through hand contact, which hand hygiene effectively prevents.

5. A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)

• A. Send wound drainage for culture and sensitivity.
• B. Institute contact precautions for staff and visitors.
• C. Use standard precautions and wear a mask.
• D. Monitor the client's white blood cell count.

Correct answer: B

Rationale: When dealing with a client suspected of having MRSA, the nurse should implement contact precautions to prevent the spread of infection. This includes using gowns and gloves, along with following proper hand hygiene practices. Sending wound drainage for culture and sensitivity may be necessary for diagnostic purposes, but it is not directly related to preventing the spread of infection in this case. Using standard precautions and wearing a mask are not sufficient when dealing with MRSA; contact precautions are specifically required to prevent transmission. Monitoring the client's white blood cell count is important in assessing infection status but is not a primary intervention to prevent the spread of MRSA.

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