Nursing Elites

1. A client has undergone an allogeneic stem cell transplant, and a nurse is initiating a protective environment. Which precaution should the nurse plan for this client?

• A. Ensure the client wears a mask when outside the room if there is construction in the area.
• B. Place the client in a room with other immunocompromised patients.
• C. Allow the client to visit public areas freely.
• D. Ensure the client does not need any special precautions.

Correct answer: A

Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to maintain a protective environment to prevent infections. Wearing a mask when outside the room, especially if there is construction in the area, helps reduce the risk of exposure to harmful pathogens. This precaution is essential as the client's immune system is compromised post-transplant. Placing the client in a room with other immunocompromised patients (choice B) would increase the risk of infections as it exposes the client to a higher pathogen load. Allowing the client to visit public areas freely (choice C) is not recommended due to the higher risk of exposure to infections. Ensuring the client does not need any special precautions (choice D) is incorrect because clients post allogeneic stem cell transplant require protective measures to prevent complications.

2. Which nursing action prevents injury to a client's eye during the administration of eye drops?

• A. Holding the tip of the container above the conjunctival sac
• B. Rinsing the eye with saline before administration
• C. Placing the client in a supine position
• D. Pressing gently on the lower eyelid to open the eye

Correct answer: A

Rationale: The correct nursing action to prevent injury to a client's eye during the administration of eye drops is to hold the tip of the container above the conjunctival sac. This technique helps to prevent direct contact between the container and the eye, reducing the risk of injury. Rinsing the eye with saline before administration (Choice B) is not a standard practice and may not necessarily prevent injury. Placing the client in a supine position (Choice C) is not directly related to preventing eye injury during eye drop administration. Pressing gently on the lower eyelid to open the eye (Choice D) is not recommended as it can potentially cause injury or discomfort to the client.

3. A healthcare provider is providing teaching about health promotion guidelines to a group of young adult male clients. Which of the following guidelines should the healthcare provider include?

• A. Obtain a tetanus booster every 5 years.
• B. Obtain a herpes zoster immunization by age 50.
• C. Have a dental examination every 6 months.
• D. Have a testicular examination every 2 years.

Correct answer: C

Rationale: Having a dental examination every 6 months is crucial for young adult males as it helps in maintaining good oral health and detecting any potential issues early on. Tetanus booster every 10 years is recommended for adults, not every 5 years (Choice A). Herpes zoster immunization is typically recommended for individuals aged 60 and older, not by age 50 (Choice B). While testicular self-examination is important for detecting testicular cancer, routine clinical testicular examinations are not generally needed every 2 years (Choice D). Therefore, the correct answer is to have a dental examination every 6 months.

4. A healthcare professional is teaching about home safety with a client. Which of the following instructions should the healthcare professional include?

• A. Unplug electronics by holding the plug
• B. Use electrical tape to secure extension cords next to baseboards on the floor
• C. To use a fire extinguisher, aim at the base of the flames
• D. Install slip-resistant rugs on tile floors

Correct answer: B

Rationale: The correct answer is to use electrical tape to secure extension cords next to baseboards on the floor. This practice helps prevent tripping and electrical hazards by keeping cords out of the way. Option A is incorrect as unplugging electronics should be done by holding the plug, not the cord itself. Option C is incorrect because when using a fire extinguisher, it should be aimed at the base of the flames, not at the top. Option D is not directly related to home safety teaching and may not be necessary for all clients, as it suggests an unnecessary change that may not improve safety.

5. During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?

• A. Mongolian spots are a normal finding in dark-skinned infants.
• B. Port wine stains are typically associated with other malformations.
• C. Telangiectatic nevi are normal and will disappear as the baby grows.
• D. The child is too young for surgical removal of these at this time.

Correct answer: C

Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.

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