Nursing Elites

1. A client who has a new diagnosis of tuberculosis should be placed in which type of room to prevent the spread of airborne pathogens?

• A. Administer isoniazid by mouth daily.
• B. Place the client in droplet isolation.
• C. Wear a surgical mask when transporting the client.
• D. Place the client in a negative pressure room.

Correct answer: D

Rationale: Clients diagnosed with tuberculosis should be placed in a negative pressure room to prevent the spread of airborne pathogens. Option A is incorrect because administering isoniazid is a treatment for tuberculosis, not a preventive measure related to infection control. Option B is incorrect as droplet isolation is used for diseases transmitted through respiratory droplets, not airborne pathogens like tuberculosis. Option C is incorrect as wearing a surgical mask is not sufficient to prevent the spread of tuberculosis in healthcare settings; placing the client in a negative pressure room is the most effective measure.

2. A nurse is assessing a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 110/70 mm Hg
• B. Heart rate of 88/min
• C. Respiratory rate of 20/min
• D. Temperature of 37.3°C (99.1°F)

Correct answer: D

Rationale: The correct answer is D because a temperature of 37.3°C (99.1°F) is slightly elevated, indicating a possible infection or inflammatory response, which should be reported to the provider for further evaluation. Choices A, B, and C are within normal limits for a client postoperative, so they do not require immediate reporting. Elevated temperature can be a sign of infection or other complications, making it a priority for reporting and further assessment.

3. A nurse is caring for a client who is receiving packed RBCs. Which of the following actions should the nurse take?

• A. Monitor the client's blood glucose level every hour
• B. Administer the blood using a microdrip set
• C. Assess the client's vital signs every 2 hours
• D. Infuse the blood within 4 hours

Correct answer: D

Rationale: The correct answer is to infuse the blood within 4 hours. This is crucial to prevent bacterial contamination and hemolysis during blood transfusions. Monitoring the client's blood glucose level every hour (Choice A) is not directly related to packed RBC transfusions. Administering the blood using a microdrip set (Choice B) may be appropriate for specific medications but is not a requirement for packed RBC transfusions. Assessing the client's vital signs every 2 hours (Choice C) is important for monitoring the client's overall condition but is not as time-sensitive as ensuring the timely infusion of packed RBCs.

4. A client is receiving intermittent tube feedings and is at risk for aspiration. What should the nurse identify as a risk factor?

• A. A residual of 65mL 1 hour postprandial.
• B. History of gastroesophageal reflux disease.
• C. Receiving a high-osmolarity formula.
• D. Receiving a feeding in a supine position.

Correct answer: B

Rationale: The correct answer is B: History of gastroesophageal reflux disease. Gastroesophageal reflux disease increases the risk of aspiration due to the potential for regurgitation of stomach contents into the esophagus and airways. Choices A, C, and D are not directly related to an increased risk of aspiration. A residual of 65mL 1 hour postprandial may indicate delayed gastric emptying but is not a direct risk factor for aspiration. Receiving a high-osmolarity formula or receiving a feeding in a supine position are not specific risk factors for aspiration unless they contribute to reflux or other related issues.

5. A nurse is providing discharge teaching to a client who has a new prescription for albuterol. Which of the following instructions should the nurse include?

• A. You should take this medication at bedtime.
• B. You might experience palpitations while taking this medication.
• C. You should rinse your mouth after using this medication.
• D. You should avoid eating before taking this medication.

Correct answer: C

Rationale: The correct answer is C: 'You should rinse your mouth after using this medication.' When providing discharge teaching for a client prescribed albuterol, the nurse should include the instruction to rinse the mouth after each use. This is important to prevent dry mouth and oral infections. Choice A is incorrect as albuterol is usually taken during the day to manage symptoms, not at bedtime. Choice B is incorrect as palpitations are not a common side effect of albuterol. Choice D is incorrect as there is no specific requirement to avoid eating before taking albuterol.

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