Nursing Elites

1. A healthcare professional is caring for a group of clients. Which of the following measures should the professional take to prevent the spread of infection?

• A. Place a client with TB in a room with negative pressure airflow
• B. Use a disposable gown for contact precautions
• C. Place a client with MRSA in a private room
• D. Use a mask for clients with influenza

Correct answer: A

Rationale: Tuberculosis is an airborne infection, and placing a client with TB in a room with negative pressure airflow helps prevent the spread of the infection by containing the pathogens. This measure is crucial as it prevents the dissemination of TB droplet nuclei to other areas. Choice B, using a disposable gown for contact precautions, is important for preventing the transmission of infections spread by direct or indirect contact. Choice C, placing a client with MRSA in a private room, is essential to prevent the spread of MRSA through contact with others. Choice D, using a mask for clients with influenza, helps prevent the spread of influenza through respiratory droplets. However, negative pressure airflow is specifically required for airborne infections like TB, making it the most appropriate choice in this scenario.

2. While being educated by a nurse, an assistive personnel (AP) is learning about proper hand hygiene. Which statement made by the AP indicates a good understanding of the teaching?

• A. There are times I should use soap and water rather than alcohol-based hand rub to clean my hands.
• B. I can use alcohol-based hand rub after using the restroom.
• C. Soap and water are only necessary if my hands are visibly dirty.
• D. Hand rub is always sufficient, regardless of the situation.

Correct answer: C

Rationale: Choice C is the correct answer because it demonstrates an understanding that soap and water should be used when hands are visibly dirty or when dealing with specific pathogens. Choice A is incorrect because it suggests the use of soap and water over alcohol-based hand rub without specifying the circumstances. Choice B is incorrect as it implies that using alcohol-based hand rub after using the restroom is always suitable. Choice D is incorrect because it states that hand rub is always enough, which is not true when hands are visibly soiled or when specific pathogens are present.

3. A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

• A. Updating the plan of care for a client who is postoperative
• B. Reinforcing teaching with a client who is learning to walk using a quad cane
• C. Reapplying a condom catheter for a client who has urinary incontinence
• D. Applying a sterile dressing to a pressure injury

Correct answer: C

Rationale: The correct answer is C - 'Reapplying a condom catheter for a client who has urinary incontinence.' This task falls within the scope of duties for an assistive personnel (AP). Updating care plans (Choice A), reinforcing teaching (Choice B), and applying sterile dressings (Choice D) typically require a higher level of training and expertise, making them tasks that should not be assigned to an AP. Assigning appropriate tasks based on skill levels ensures safe and effective patient care.

4. A client who is post-op following a partial colectomy has an NG tube set on low continuous suction. The client complains of a sore throat and asks when the NG tube will be removed. Which response by the nurse is appropriate at this time?

• A. When the GI tract is working again, in about three to five days, the tube can be removed.
• B. The tube will be removed once your nausea improves.
• C. You can expect the tube to be removed in about a week.
• D. The tube will be removed once the drainage stops.

Correct answer: A

Rationale: The correct response is A: 'When the GI tract is working again, in about three to five days, the tube can be removed.' After a partial colectomy, the GI tract needs time to recover and start functioning properly. The NG tube is typically removed when peristalsis returns, indicating GI function restoration, which usually occurs within 3-5 days post-op. Choice B is incorrect because the removal of the NG tube is not solely based on nausea improvement. Choice C is incorrect as it provides a longer duration for tube removal than is usually necessary. Choice D is incorrect as the cessation of drainage alone does not dictate NG tube removal; the return of GI function is the primary indicator.

5. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?

• A. Swelling and redness in the affected leg
• B. Pain in the affected leg
• C. Warmth and tenderness in the affected leg
• D. A positive Homans' sign

Correct answer: D

Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.

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