Nursing Elites

1. A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take?

• A. Wear a gown within 3 feet of the client
• B. Maintain a distance of 6 feet from the client
• C. Wear a surgical mask within 3 feet of the client
• D. Remove gloves before leaving the room

Correct answer: C

Rationale: The correct action for the nurse to take when maintaining droplet precautions for a client with meningitis is to wear a surgical mask within 3 feet of the client. This is essential to prevent the transmission of meningitis via respiratory droplets. Choice A is incorrect because wearing a gown is not specifically required for droplet precautions. Choice B suggests maintaining a distance of 6 feet, which is more applicable to airborne precautions, not droplet precautions. Choice D is incorrect as gloves should be removed and disposed of properly, but it is not related to droplet precautions specifically.

2. A client with diabetes is being discharged. What is an essential teaching point?

• A. Monitor blood sugar levels once a week
• B. Instruct the client to administer insulin before meals
• C. Teach the client to exercise regularly to maintain glucose control
• D. Administer oral hypoglycemics as needed

Correct answer: B

Rationale: Instructing the client to administer insulin before meals is a crucial teaching point for a client with diabetes. This action ensures proper glucose management by helping to control blood sugar levels. Monitoring blood sugar levels once a week (Choice A) may not be frequent enough to manage diabetes effectively. While regular exercise (Choice C) is beneficial for glucose control, the immediate administration of insulin is more critical at the time of discharge. Administering oral hypoglycemics as needed (Choice D) is inappropriate as it does not address the need for insulin administration for a client being discharged.

3. What is an early sign that suctioning is needed for a client with a tracheostomy?

• A. Bradycardia
• B. Irritability
• C. Hypotension
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early sign that suctioning is needed for a client with a tracheostomy. When secretions accumulate in the airway, it can lead to discomfort and irritability in the client. Bradycardia, hypotension, and decreased oxygen saturation are usually later signs of inadequate airway clearance and oxygenation. Bradycardia may indicate severe hypoxia, while hypotension and decreased oxygen saturation are consequences of prolonged airway obstruction.

4. What should be included in dietary teaching for a client with chronic kidney disease?

• A. Increase potassium-rich foods in the diet
• B. Limit potassium and phosphorus intake
• C. Increase intake of protein-rich foods
• D. Increase fluid intake to prevent dehydration

Correct answer: B

Rationale: The correct answer is to limit potassium and phosphorus intake for a client with chronic kidney disease. Excessive potassium and phosphorus can be harmful to individuals with compromised kidney function. Option A is incorrect because increasing potassium-rich foods can exacerbate hyperkalemia in individuals with kidney disease. Option C may not be ideal as excessive protein intake can put extra strain on the kidneys. Option D is not the priority; while adequate fluid intake is important, it is not the primary focus when teaching dietary considerations for chronic kidney disease.

5. A nurse is assessing a client who has a brainstem injury. The nurse should expect the client to exhibit which of the following findings?

• A. Decerebrate posturing.
• B. Hypervigilance.
• C. Absence of deep tendon reflexes.
• D. Glasgow Coma Scale score of 15.

Correct answer: A

Rationale: The correct answer is A: Decerebrate posturing. Decerebrate posturing is an abnormal body posture characterized by rigid extension of the arms and legs, which indicates severe brainstem injury affecting the midbrain and pons. This posture suggests dysfunction or damage to neural pathways controlling muscle tone. Choice B, hypervigilance, is not typically associated with brainstem injury but rather with increased alertness and arousal. Choice C, absence of deep tendon reflexes, is not a specific finding related to brainstem injury. Choice D, a Glasgow Coma Scale score of 15, indicates a fully awake and alert state, which is not expected in a client with a brainstem injury.

Similar Questions