Nursing Elites

1. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?

• A. drowsiness
• B. complaint of nausea
• C. pulse rate of 92
• D. restlessness

Correct answer: D

Rationale: Restlessness is often a sign of respiratory distress or secretion build-up, indicating the need for suctioning. While drowsiness (choice A) can be a sign of hypoxia, it is not as immediate an indication for suctioning as restlessness. Complaint of nausea (choice B) and a pulse rate of 92 (choice C) are not directly related to the need for suctioning in a client on a volume-cycled ventilator.

2. After a client was taken off the ventilator following surgery, they have a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

• A. Allow the client to suck on ice chips
• B. Provide mints to freshen the breath
• C. Perform frequent oral care with a tooth sponge
• D. Swab the mouth with glycerin swabs

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure to provide comfort to a client with a nasogastric tube draining bile-colored liquids. This measure helps to maintain oral hygiene, prevent dryness, and enhance overall comfort. Allowing the client to suck on ice chips may not address oral hygiene needs, providing mints focuses more on breath freshness rather than comfort, and swabbing the mouth with glycerin swabs may not effectively address oral care needs.

3. A 20-year-old client has an infected leg wound from a motorcycle accident and has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:

• A. Visitors must wear a mask and a gown
• B. There are no special requirements for visitors of clients on contact precautions
• C. Visitors should wash their hands before and after touching the client
• D. Visitors -

Correct answer: C

Rationale: The correct answer is C: 'Visitors should wash their hands before and after touching the client.' When a client is on contact precautions, it is essential for visitors to practice good hand hygiene to prevent the spread of infection. While wearing a mask and a gown might be necessary for healthcare providers, it is not typically required for visitors. Option B is incorrect because there are indeed special requirements for visitors on contact precautions, including practicing good hand hygiene. Option D is incomplete and does not provide any guidance on infection prevention measures.

4. During the care of a client with a salmonella infection, what is the primary nursing intervention to limit transmission?

• A. Wash hands thoroughly before and after client contact
• B. Wear gloves when in contact with body secretions
• C. Double glove when in contact with feces or vomitus
• D. Wear gloves when disposing of contaminated linens

Correct answer: A

Rationale: The correct answer is to wash hands thoroughly before and after client contact when caring for a client with a salmonella infection. This approach is crucial in preventing the transmission of the infection. While wearing gloves when in contact with body secretions (Choice B), double gloving when in contact with feces or vomitus (Choice C), and wearing gloves when disposing of contaminated linens (Choice D) are important infection control measures, the primary intervention to limit the spread of salmonella is proper hand hygiene.

5. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?

• A. Cut the child's hair short to remove the nits
• B. Apply warm soaks to the head twice daily
• C. Wash the child's linen and clothing in a bleach solution
• D. Application of pediculicides

Correct answer: D

Rationale: Pediculicides are the recommended treatment for lice and should be used to eliminate the infestation.

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