Nursing Elites

1. A nurse is planning care for a client who has tuberculosis. Which of the following actions should the nurse take to prevent the transmission of the disease?

• A. Place the client in droplet isolation.
• B. Place the client in airborne isolation.
• C. Wear a surgical mask when providing care to the client.
• D. Keep the client's door closed at all times.

Correct answer: B

Rationale: The correct answer is B: 'Place the client in airborne isolation.' Tuberculosis is an airborne disease transmitted through droplet nuclei. Placing the client in airborne isolation helps prevent the spread of the disease to others. Choice A, placing the client in droplet isolation, is incorrect because tuberculosis is not transmitted through large droplets. Choice C, wearing a surgical mask when providing care to the client, is not sufficient as airborne precautions are necessary. Choice D, keeping the client's door closed at all times, does not directly address the prevention of disease transmission in this case.

2. A nurse is assessing a client who is experiencing acute pain. Which of the following manifestations should the nurse expect?

• A. Hypertension
• B. Bradycardia
• C. Diaphoresis
• D. Piloerection

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common manifestation of acute pain caused by increased sympathetic nervous system activity. This response is the body's way of trying to regulate body temperature during the stress response. Choices A, B, and D are incorrect. Hypertension (Choice A) and tachycardia (not bradycardia as in Choice B) are more likely responses to acute pain due to sympathetic nervous system activation. Piloerection (Choice D), also known as goosebumps, is not a typical manifestation of acute pain.

3. A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Serum potassium level of 4.2 mEq/L
• B. Blood pressure of 138/84 mm Hg
• C. Platelet count of 150,000/mm³
• D. INR of 2.0

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

4. A client with chronic kidney disease is being taught by a nurse about managing protein intake. Which of the following instructions should the nurse include?

• A. You should increase your intake of high-protein foods.
• B. You should limit your intake of high-protein foods.
• C. You should avoid all protein sources to prevent further kidney damage.
• D. You should increase your intake of animal protein.

Correct answer: B

Rationale: The correct answer is B: 'You should limit your intake of high-protein foods.' Clients with chronic kidney disease should restrict their intake of high-protein foods to lessen the workload on the kidneys and prevent further kidney damage. Option A is incorrect as increasing intake of high-protein foods can exacerbate the condition. Option C is incorrect as avoiding all protein sources is not advisable, as some proteins are essential for overall health. Option D is incorrect as increasing the intake of animal protein can put more strain on the kidneys due to the metabolites produced during protein breakdown.

5. What is the most concerning electrolyte imbalance for a patient receiving digoxin?

• A. Hyperkalemia
• B. Hypokalemia
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: B

Rationale: The correct answer is Hypokalemia. Hypokalemia is the most concerning electrolyte imbalance for a patient receiving digoxin because it can increase the risk of digoxin toxicity. Low potassium levels can potentiate the effects of digoxin on the heart, leading to serious cardiac arrhythmias. Hyperkalemia (Choice A) is not typically associated with digoxin use. Hyponatremia (Choice C) and Hypercalcemia (Choice D) are not directly related to digoxin therapy and do not pose the same risk of toxicity.

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