Nursing Elites

1. A healthcare professional is reviewing the medical history of a client with dementia. Which of the following findings should be addressed immediately?

• A. Frequent episodes of wandering at night
• B. Restlessness and agitation
• C. Mild confusion during the day
• D. Incontinence

Correct answer: B

Rationale: Restlessness and agitation in clients with dementia should be addressed immediately as they can indicate underlying causes such as pain, discomfort, or unmet needs. Addressing these symptoms promptly can help prevent the escalation of behavioral issues and improve the client's quality of life. While frequent episodes of wandering at night, mild confusion during the day, and incontinence are also important issues to address in clients with dementia, restlessness and agitation usually require immediate attention to ensure the safety and well-being of the client.

2. A healthcare professional is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the healthcare professional recommend?

• A. Suction the airway every hour
• B. Keep the head of the bed at 30 degrees
• C. Change the ventilator tubing every day
• D. Administer a bronchodilator every 2 hours

Correct answer: B

Rationale: The correct answer is to keep the head of the bed at 30 degrees. This position helps reduce the risk of aspiration and improves ventilation. Suctioning the airway every hour may lead to mucosal damage and increase the risk of infection. Changing the ventilator tubing every day is not necessary unless there are specific indications to do so, as it can increase the risk of contamination and infection. Administering a bronchodilator every 2 hours is not a standard practice and should be done based on the client's individualized treatment plan.

3. A charge nurse is discussing the responsibility of nurses caring for clients who have C. difficile. Which of the following information should the nurse include in the teaching?

• A. Assign the client to a room with a negative air-flow system
• B. Use alcohol-based hand sanitizer when leaving the client's room
• C. Clean contaminated surfaces in the client's room with a phenol solution
• D. Have family members wear a gown and gloves when visiting

Correct answer: D

Rationale: The correct answer is D because having family members wear a gown and gloves when visiting clients with C. difficile is crucial to prevent the transmission of the infection. Options A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning contaminated surfaces with a phenol solution are not specific measures for preventing the spread of C. difficile.

4. What are the steps in providing perineal care to a patient?

• A. Clean the perineal area with soap and water
• B. Use antiseptic wipes to prevent infection
• C. Pat the area dry after cleaning
• D. Always use gloves when performing care

Correct answer: A

Rationale: The correct answer is A: Clean the perineal area with soap and water. This step is essential in preventing infection and promoting hygiene. Using antiseptic wipes (choice B) is not a standard practice for perineal care; soap and water are preferred. While patting the area dry after cleaning (choice C) is important, the initial step of cleaning with soap and water is crucial. Using gloves (choice D) is a good practice to prevent the spread of infection, but it is not the initial step in providing perineal care.

5. A client is learning to use a cane due to left-leg weakness. Which instruction is correct?

• A. Use the cane on the stronger side of the body
• B. Maintain two points of support on the floor at all times
• C. Advance the cane and the strong leg together
• D. Advance the cane 30 to 45 cm with each step

Correct answer: B

Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.

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