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. During a complete bed bath for a client, after removing the gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?

• A. Face
• B. Feet
• C. Chest
• D. Arms

Correct answer: A

Rationale: When performing a complete bed bath, it is essential to wash the face first. Washing the face initially helps to maintain the client's privacy and comfort. Additionally, starting with the face prevents re-contamination of already cleaned areas. Washing the feet first (Choice B) is not ideal as it can lead to potential contamination of the upper body parts. Starting with the chest (Choice C) or arms (Choice D) is not recommended due to the risk of water dripping onto the client's face, causing discomfort and compromising privacy.

3. At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, where should the nurse place the stethoscope?

• A. Second intercostal space to the right of the sternum
• B. Fifth intercostal space to the left of the sternum
• C. Third intercostal space to the left of the sternum
• D. Fourth intercostal space at the midclavicular line

Correct answer: A

Rationale: The correct location to auscultate the aortic valve is the second intercostal space to the right of the sternum. This area corresponds to the aortic valve area where aortic valve sounds are best heard. Choices B, C, and D are incorrect for auscultating the aortic valve. The fifth intercostal space to the left of the sternum is where the mitral valve is best heard, the third intercostal space to the left of the sternum is where the pulmonic valve is best heard, and the fourth intercostal space at the midclavicular line is where the tricuspid valve is best auscultated.

4. A client has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should be administered to soften the feces?

• A. Oil retention
• B. Soapsuds
• C. Saline
• D. Hypertonic

Correct answer: A

Rationale: An oil retention enema is the most appropriate choice to soften and lubricate the feces before digital removal. Oil retention enemas help in making the stool easier to remove digitally due to their lubricating properties. Soapsuds, saline, and hypertonic enemas are not specifically designed to soften feces and are used for different purposes. Soapsuds enemas are used for cleansing, saline enemas for bowel evacuation, and hypertonic enemas for bowel distension in preparation for diagnostic procedures.

5. A client with heart failure is being taught by a nurse on reducing daily sodium intake. What is the most important factor in determining the client's ability to learn new dietary habits?

• A. The involvement of the client in planning the change
• B. The presence of a dietitian during the teaching
• C. The use of dietary supplements
• D. The client's family support

Correct answer: A

Rationale: The most crucial factor in the client's ability to learn new dietary habits is their involvement in planning the change. When clients actively participate in setting their dietary goals, they are more likely to commit to and adhere to the changes. This empowerment fosters a sense of ownership and responsibility, enhancing the chances of successful dietary modifications. The presence of a dietitian, use of dietary supplements, and family support, while beneficial, are not as critical as the client's active participation in planning the dietary changes.

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