Nursing Elites

1. A client has a stool culture positive for C. difficile. What action should the nurse take?

• A. Place the client in a negative pressure room
• B. Use alcohol-based hand rub after providing care
• C. Wear a face shield before entering the room
• D. Place the client in a private room

Correct answer: D

Rationale: When caring for a client with a C. difficile infection, it is essential to isolate them in a private room to prevent the spread of spores through contact with surfaces. Placing the client in a negative pressure room (Choice A) is not necessary for C. difficile. Using alcohol-based hand rub (Choice B) and wearing a face shield (Choice C) are important infection control measures but are not specific to the isolation requirements for C. difficile.

2. A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the nurse?

• A. Aspirate the irrigation solution from the bladder
• B. Insert the tip of the irrigation syringe into the catheter opening
• C. Apply sterile gloves
• D. Open the flow clamp to the irrigating fluid infusion tubing

Correct answer: C

Rationale: The correct action for the nurse to take before performing a closed intermittent bladder irrigation is to apply sterile gloves. Sterile gloves help maintain asepsis, reduce the risk of infection, and ensure patient safety during the procedure. Aspirating the irrigation solution from the bladder (Choice A) is not a standard step in closed intermittent bladder irrigation. Inserting the tip of the irrigation syringe into the catheter opening (Choice B) can introduce contaminants into the system. Opening the flow clamp to the irrigating fluid infusion tubing (Choice D) should only be done after ensuring all equipment is ready and the nurse is gloved to maintain sterility.

3. A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

• A. Administer oxygen
• B. Change the client's position
• C. Increase IV fluids
• D. Call the healthcare provider

Correct answer: B

Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps improve placental blood flow, reducing stress on the fetus. Administering oxygen may be necessary if changing position does not resolve the decelerations. Increasing IV fluids is not the priority in this situation as it won't directly address the cause of late decelerations. Calling the healthcare provider should be done after immediate interventions like changing the client's position have been implemented and assessed.

4. A nurse is caring for a client who had a stroke and is showing signs of dysphagia. Which of the following findings should the nurse recognize as an indication of this condition?

• A. Abnormal movements of the mouth
• B. Inability to stand without assistance
• C. Paralysis of the right arm
• D. Loss of appetite

Correct answer: A

Rationale: Abnormal movements of the mouth are a common indication of dysphagia, a condition that impairs swallowing function. In clients who have had a stroke, dysphagia can increase the risk of aspiration, leading to serious complications. Inability to stand without assistance (Choice B) is more indicative of motor deficits following a stroke rather than dysphagia. Paralysis of the right arm (Choice C) is a manifestation of hemiplegia, which is common in stroke but not directly related to dysphagia. Loss of appetite (Choice D) may occur in individuals with dysphagia but is not a direct indicator of the condition itself.

5. A nurse is caring for a client receiving radiation treatments for cancer. The client states he is experiencing dryness, redness, and scaling at the treatment area. Which of the following should the nurse instruct the client to do?

• A. Sit in the sun for 15 minutes per day.
• B. Apply moist heat to the area twice daily.
• C. Liberally apply prescribed lotion to the area.
• D. Wash the affected area daily with antimicrobial soap.

Correct answer: C

Rationale: The nurse should instruct the client to liberally apply prescribed lotion to the treatment area. Prescribed hydrating lotions help soothe and protect irradiated skin, reducing dryness, redness, and scaling. Sitting in the sun can further damage the skin. Applying moist heat may exacerbate the skin condition. Washing the area with antimicrobial soap can be too harsh and further irritate the skin.

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