Nursing Elites

1. A nurse is providing discharge instructions to a client with home oxygen therapy. What safety measure should the nurse emphasize?

• A. Allow smoking in designated outdoor areas
• B. Keep oxygen tanks upright and away from heat sources
• C. Store oxygen tanks in a closet when not in use
• D. Keep oxygen equipment at least 10 feet away from open flames

Correct answer: B

Rationale: The correct safety measure that the nurse should emphasize is to keep oxygen tanks upright and away from heat sources. This is crucial to prevent the risk of fire or explosion. Choice A is incorrect as smoking near oxygen can lead to a fire hazard. Choice C is also incorrect as storing oxygen tanks in enclosed spaces can be dangerous. Choice D, although related to safety, does not address the immediate risk of keeping oxygen tanks away from heat sources.

2. What are the nursing interventions for a patient with neutropenia?

• A. Monitor for signs of infection and administer antibiotics
• B. Isolate the patient and provide a low-microbial diet
• C. Monitor vital signs and avoid unnecessary invasive procedures
• D. Encourage the patient to engage in social activities

Correct answer: A

Rationale: The correct nursing interventions for a patient with neutropenia include monitoring for signs of infection and administering antibiotics. Neutropenia is characterized by a low neutrophil count, which increases the risk of infections. Monitoring for signs of infection allows for early detection and prompt treatment, while administering antibiotics helps prevent or treat any infections that may occur. Isolating the patient and providing a low-microbial diet (Choice B) are not necessary unless the patient develops an active infection. Monitoring vital signs and avoiding unnecessary invasive procedures (Choice C) are important but do not specifically address the increased infection risk in neutropenic patients. Encouraging the patient to engage in social activities (Choice D) is not appropriate for a neutropenic patient due to the risk of exposure to infectious agents.

3. A nurse is reviewing the medical history of a client with dementia. Which of the following findings should the nurse address first?

• A. Restlessness and agitation
• B. Decreased respiratory rate
• C. Wandering during the night
• D. Incontinence

Correct answer: A

Rationale: In a client with dementia, addressing restlessness and agitation is a priority because these symptoms can exacerbate dementia and lead to further complications. Restlessness and agitation can indicate underlying issues such as pain, discomfort, or unmet needs, which should be promptly assessed and managed to improve the client's quality of life. Decreased respiratory rate, wandering during the night, and incontinence are important to address but do not pose immediate risks to the client's well-being compared to the potential effects of unmanaged restlessness and agitation in dementia.

4. What is the most important action when providing wound care to a client with a pressure ulcer?

• A. Apply a dry, sterile dressing to the wound
• B. Cleanse the wound with normal saline
• C. Perform a wound culture before applying ointment
• D. Cover the wound with a wet-to-dry dressing

Correct answer: C

Rationale: Performing a wound culture before applying ointment is crucial when providing wound care to a client with a pressure ulcer. This action helps identify any underlying infections, allowing healthcare providers to select the most appropriate treatment. Options A, B, and D are not as critical as performing a wound culture, as they focus on wound dressing and cleansing rather than identifying potential infections.

5. A nurse is caring for a client post-abdominal surgery who has an NG tube. The client reports nausea and a decrease in gastric output. What should the nurse do first?

• A. Turn the client onto their left side
• B. Irrigate the NG tube with sterile water
• C. Increase the suction pressure to relieve the blockage
• D. Remove the NG tube and replace it with a new one

Correct answer: B

Rationale: The correct answer is to irrigate the NG tube with sterile water first. This action helps to relieve blockages that may be causing the decrease in gastric output and nausea. Turning the client onto their left side may not directly address the issue with the NG tube. Increasing the suction pressure can further exacerbate the problem and should not be done without assessing the situation first. Removing the NG tube and replacing it with a new one is a more invasive step that should be considered only if other measures are unsuccessful.

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