Nursing Elites

1. A healthcare professional is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the healthcare professional initiate?

• A. Contact
• B. Droplet
• C. Airborne
• D. Protective

Correct answer: B

Rationale: The correct answer is B: Droplet. Droplet precautions are required for infections that spread via droplets larger than 5 microns in diameter, such as pharyngeal diphtheria. Contact precautions are used for diseases that spread by direct or indirect contact. Airborne precautions are for diseases that spread through small particles in the air. Protective precautions are not a standard precautionary measure for specific infections like pharyngeal diphtheria.

2. A client postoperative expresses pain during dressing changes. What should the nurse prioritize?

• A. Administer pain medication 45 minutes before changing the client’s dressing.
• B. Change the dressing less frequently.
• C. Apply a topical anesthetic before removing the dressing.
• D. Use a non-adherent dressing to reduce pain.

Correct answer: A

Rationale: Administering pain medication before changing the dressing is the priority action as it will help alleviate the client's pain and improve comfort. Choice B, changing the dressing less frequently, may hinder proper wound care and healing. Applying a topical anesthetic (choice C) might offer some relief but systemic pain medication is more effective. Using a non-adherent dressing (choice D) can reduce pain during dressing changes, but addressing immediate pain with medication is the most appropriate intervention in this case.

3. A client with a history of seizures is prescribed phenytoin (Dilantin). What side effect should the healthcare provider report immediately?

• A. Increased appetite
• B. Dry mouth
• C. Nausea and vomiting
• D. Gingival hyperplasia

Correct answer: D

Rationale: Gingival hyperplasia is a significant side effect associated with phenytoin therapy. It is characterized by an overgrowth of gum tissue, which can lead to issues such as difficulty in speaking, eating, and maintaining proper oral hygiene. This condition can progress rapidly and may require immediate intervention by the healthcare provider to prevent further complications. Increased appetite, dry mouth, and nausea/vomiting are common side effects of various medications, but they are not as urgent or serious as gingival hyperplasia in a client taking phenytoin.

4. A parent asks a nurse about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

• A. A 10-month-old infant can pull up to a standing position.
• B. A 6-month-old infant can walk with assistance.
• C. A 12-month-old infant can jump with both feet.
• D. An 8-month-old infant can crawl on hands and knees.

Correct answer: A

Rationale: The correct answer is A. By 10 months, infants can typically pull up to a standing position as part of their physical development. Walking with assistance usually begins around 9-12 months, not at 6 months (choice B). Jumping with both feet is a skill that usually develops around 24 months, not at 12 months (choice C). Crawling on hands and knees typically starts around 6-9 months, not at 8 months (choice D). Therefore, the most accurate information to include for an infant's expected physical development at 10 months is the ability to pull up to a standing position.

5. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

• A. Using a cuff that is too small will result in an inaccurately high reading.
• B. Using a cuff that is too large will result in an inaccurately low reading.
• C. The regular size cuff is appropriate for all clients.
• D. You should use a cuff of any size as long as it fits.

Correct answer: A

Rationale: The correct answer is A: 'Using a cuff that is too small will result in an inaccurately high reading.' When obtaining blood pressure for an obese client, it is crucial to use a larger cuff to ensure an accurate reading. Choice B is incorrect because using a cuff that is too large for an obese client would actually result in an inaccurately low reading. Choice C is incorrect as a regular size cuff is not appropriate for obese clients due to their larger arm circumference. Choice D is incorrect because using a cuff of any size as long as it fits is not suitable for obtaining accurate blood pressure readings on an obese client.

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