Nursing Elites

1. A community nurse is instructing a group of high school students about the transmission of hepatitis A. Which mode of transmission should the nurse include in the teaching?

• A. Sexual contact
• B. Airborne droplets
• C. Fecal-oral
• D. Bloodborne

Correct answer: C

Rationale: The correct answer is C: Fecal-oral. Hepatitis A is primarily transmitted through the fecal-oral route, often from consuming contaminated food or water. Choice A, sexual contact, is not a typical mode of transmission for hepatitis A. Choice B, airborne droplets, is more characteristic of diseases like influenza or tuberculosis. Choice D, bloodborne transmission, is more relevant to hepatitis B and C, not hepatitis A.

2. A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?

• A. Feeling flushed and warm
• B. Abdominal fullness
• C. Swollen lips
• D. Metallic taste in the mouth

Correct answer: C

Rationale: Swollen lips indicate a potential allergic reaction or anaphylaxis to the contrast dye used during the procedure, which requires immediate medical intervention. Abdominal fullness and metallic taste are common side effects of IV urography and can be managed without urgent intervention. Feeling flushed and warm may also be a common reaction during the procedure and does not indicate a life-threatening situation like an allergic reaction.

3. A nurse is caring for a client with a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

• A. Tidaling with spontaneous respirations
• B. Drainage collection chamber is 1/3 full
• C. 1 cm of water present in the water seal chamber
• D. Suction chamber pressure of -20 cm H2O

Correct answer: C

Rationale: 1 cm of water in the water seal chamber is insufficient to ensure proper functioning of the chest tube. The water seal chamber typically requires a water level of 2 cm. Tidaling with spontaneous respirations (choice A) is an expected finding indicating proper functioning. Having the drainage collection chamber 1/3 full (choice B) is within the normal range. A suction chamber pressure of -20 cm H2O (choice D) is an appropriate level for chest tube drainage.

4. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

• A. Apply skin preparation to wound edges
• B. Cleanse the wound with normal saline
• C. Don sterile gloves
• D. Determine the client's pain level

Correct answer: D

Rationale: The correct answer is to determine the client's pain level first. Assessing the client's pain is crucial before proceeding with any procedure, including dressing changes. This step ensures that appropriate pain management measures can be implemented, making the wound care process as comfortable as possible for the patient. Applying skin preparation to wound edges (choice A) can come after addressing the pain. While cleansing the wound with normal saline (choice B) and donning sterile gloves (choice C) are important steps in wound care, they should follow the assessment of the client's pain level to prioritize the patient's comfort and well-being.

5. While caring for a newborn under phototherapy lights, what is an appropriate nursing action?

• A. Ensure an eye shield is covering the eyes
• B. Apply lotion to the exposed skin
• C. Offer glucose water between feedings
• D. Discontinue breastfeeding during treatment

Correct answer: A

Rationale: The correct answer is to ensure an eye shield is covering the eyes. This action is essential to protect the newborn's eyes from the bright light used in phototherapy. Applying lotion to the exposed skin (Choice B) is not necessary and may interfere with the treatment. Offering glucose water between feedings (Choice C) is not indicated and may not be appropriate for a newborn undergoing phototherapy. Discontinuing breastfeeding during treatment (Choice D) is not recommended as breastfeeding should be continued unless contraindicated.

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