Nursing Elites

1. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a private room with negative airflow.
• B. Wear an N95 respirator when caring for the client.
• C. Place the client in a positive pressure room.
• D. Maintain the client on droplet precautions.

Correct answer: A

Rationale: The correct answer is to place the client in a private room with negative airflow. This is crucial for preventing the spread of tuberculosis (TB) infection. Option B, wearing an N95 respirator when caring for the client, is important for staff protection but does not address the need for isolation precautions. Option C, placing the client in a positive pressure room, is incorrect as TB clients should be in negative pressure rooms to prevent the spread of airborne pathogens. Option D, maintaining the client on droplet precautions, is not sufficient for TB, which requires airborne precautions.

2. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include?

• A. Establish a toileting schedule for the client.
• B. Use clothing with buttons and zippers.
• C. Discourage physical activity during the day.
• D. Engage the client in activities that increase sensory stimulation.

Correct answer: A

Rationale: The correct answer is A: Establish a toileting schedule for the client. A toileting schedule helps manage incontinence and prevent accidents, promoting client dignity. Choice B is incorrect because clothing with buttons and zippers may be difficult for a client with dementia to manage independently. Choice C is incorrect as physical activity during the day is beneficial for clients with dementia. Choice D is incorrect as activities that increase sensory stimulation may be overwhelming for a client with dementia.

3. A client on glucocorticoid therapy is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I have my eyes examined annually.
• B. I take a calcium vitamin supplement daily.
• C. I limit my intake of foods with potassium.
• D. I consistently take my medication between 8 and 9 each evening.

Correct answer: B

Rationale: The correct answer is B. Taking a calcium supplement daily is crucial for clients on glucocorticoid therapy to prevent osteoporosis, a common side effect of long-term use. Choice A is unrelated to glucocorticoid therapy. Choice C, limiting potassium intake, is not necessary for clients on glucocorticoids. Choice D, taking medication consistently in the evening, is important but does not specifically address the side effects of glucocorticoid therapy.

4. A nurse is caring for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse take to prevent aspiration?

• A. Flush the NG tube with 0.9% sodium chloride before feedings.
• B. Place the client in a high Fowler's position during feedings.
• C. Administer the feedings over 30 minutes.
• D. Warm the formula before administering it.

Correct answer: B

Rationale: The correct answer is to place the client in a high Fowler's position during enteral feedings. This position helps prevent aspiration by promoting the downward flow of the feeding and reducing the risk of regurgitation into the lungs. Choice A is incorrect because flushing the NG tube with 0.9% sodium chloride before feedings is not directly related to preventing aspiration. Choice C is incorrect because the rate of administration does not directly impact the risk of aspiration. Choice D is incorrect because warming the formula does not specifically address the prevention of aspiration during enteral feedings.

5. If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?

• A. Time the medication was given
• B. The client's response to the medication
• C. The dose that was administered
• D. Reason for the error

Correct answer: A

Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.

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