Nursing Elites

1. A male client with unstable angina needs a cardiac catheterization. The healthcare provider explains the risks and benefits of the procedure and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take?

• A. Answer the client’s specific questions with a short, understandable explanation
• B. Postpone the procedure until the client understands the risks and benefits
• C. Call the client’s next of kin and ask them to provide verbal consent
• D. Page the healthcare provider to return and provide additional explanation

Correct answer: D

Rationale: The nurse should ask the healthcare provider to return and provide further explanation to the client. The healthcare provider is the one who can address the risks and benefits of the procedure in detail, ensuring the client receives accurate information before providing consent.

2. While changing a client’s post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?

• A. Force oral fluids
• B. Request a nutrition consult
• C. Initiate contact precautions
• D. Limit visitors to immediate family only

Correct answer: C

Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.

3. The healthcare provider is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the healthcare provider use to cleanse the pressure ulcer?

• A. Lightly coat the wound with povidone-iodine solution
• B. Irrigate the wound with sterile normal saline
• C. Flush the wound with sterile hydrogen peroxide
• D. Remove the eschar with a wet-to-dry dressing

Correct answer: B

Rationale: The correct technique to cleanse a wound when the prescription does not specify a cleaning method is to irrigate the wound with sterile normal saline. Sterile normal saline is the preferred solution for wound cleaning as it is gentle and does not damage healthy tissues. It helps in removing debris and maintaining a moist environment conducive to healing. Povidone-iodine solution and hydrogen peroxide can be harsh on tissues and delay wound healing. Removing eschar with a wet-to-dry dressing is a mechanical debridement method and should not be done without proper assessment and healthcare provider's order.

4. When faced with caring for a close friend in a professional setting, which action should the staff member take first?

• A. Notify the friend that all medical information will be kept confidential.
• B. Explain the relationship to the charge nurse and ask for reassignment.
• C. Approach the client and ask if the assignment is uncomfortable.
• D. Accept the assignment but protect the client's confidentiality.

Correct answer: B

Rationale: When faced with caring for a close friend in a professional setting, the staff member should first explain the relationship to the charge nurse and ask for reassignment. This is important to maintain professional boundaries, prevent conflicts of interest, and ensure that the care provided is unbiased and without compromising the friend's confidentiality. Choice A is incorrect because the priority should be on professional boundaries rather than informing the friend about confidentiality. Choice C is not appropriate as it puts the burden on the client to address any discomfort. Choice D is incorrect as accepting the assignment without addressing the potential conflict of interest could lead to compromised care.

5. The client is being instructed on the proper use of a metered-dose inhaler. Which instruction should be provided to ensure the optimal benefits from the drug?

• A. Fill your lungs with air through your mouth and then compress the inhaler.
• B. Compress the inhaler while slowly breathing in through your mouth.
• C. Compress the inhaler while inhaling quickly through your nose.
• D. Exhale completely after compressing the inhaler and then inhale.

Correct answer: B

Rationale: The correct technique for using a metered-dose inhaler involves compressing the inhaler while slowly breathing in through the mouth. This method helps ensure that the medication reaches deep into the lungs, allowing for optimal bronchodilation effect. Inhaling quickly through the nose or filling the lungs with air before compressing the inhaler are not recommended techniques for using a metered-dose inhaler effectively.

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