Nursing Elites

1. A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify which of the following as a risk factor for developing infections?

• A. Increased physical activity
• B. Lowered immune system function
• C. Regular health screenings
• D. Proper nutrition

Correct answer: B

Rationale: The correct answer is B: Lowered immune system function. In older adults, a decline in immune system function increases the risk of developing infections. Increased physical activity (choice A) and proper nutrition (choice D) generally support immune function and overall health, reducing the risk of infections. Regular health screenings (choice C) are important for early detection of health issues but do not directly increase the risk of infections.

2. A nurse is caring for a client with a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

• A. Tidaling with spontaneous respirations
• B. Drainage collection chamber is 1/3 full
• C. 1 cm of water present in the water seal chamber
• D. Suction chamber pressure of -20 cm H2O

Correct answer: C

Rationale: 1 cm of water in the water seal chamber is insufficient to ensure proper functioning of the chest tube. The water seal chamber typically requires a water level of 2 cm. Tidaling with spontaneous respirations (choice A) is an expected finding indicating proper functioning. Having the drainage collection chamber 1/3 full (choice B) is within the normal range. A suction chamber pressure of -20 cm H2O (choice D) is an appropriate level for chest tube drainage.

3. A healthcare provider is providing education to a client about atorvastatin. Which of the following should be included?

• A. Monitor for muscle pain
• B. Avoid sun exposure
• C. Report any gastrointestinal symptoms
• D. Check liver function tests

Correct answer: A

Rationale: Corrected Rationale: Atorvastatin can cause muscle pain and liver function abnormalities. Monitoring for muscle pain is essential as it can be a sign of a serious side effect called rhabdomyolysis. While liver function tests are necessary before starting atorvastatin, checking them continuously may not be required. Avoiding sun exposure and reporting gastrointestinal symptoms are not directly associated with atorvastatin use.

4. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?

• A. Use sterile gloves only as necessary
• B. Restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray
• C. Keep the dressing tray on a nearby surface
• D. Avoid speaking during the procedure

Correct answer: B

Rationale: The correct action to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray. Any contact with the sterile field by non-sterile items makes the field contaminated and requires restarting the procedure to maintain sterility. Choice A is incorrect because sterile gloves should always be used during a sterile procedure to prevent contamination. Choice C is incorrect as the dressing tray should be placed on a sterile surface, not on the client's bed, to maintain sterility. Choice D is also incorrect as talking during the procedure does not necessarily lead to contamination if proper aseptic technique is maintained.

5. A nurse receives a report on four clients. Which client should the nurse assess first?

• A. A client scheduled for chemotherapy with a hemoglobin of 9 g/dL
• B. A client 24 hours post-TURP with small blood clots in the catheter
• C. A client receiving a blood transfusion who reports low back pain
• D. A client with a new colostomy and a reddish-pink stoma

Correct answer: C

Rationale: The correct answer is C. Low back pain during a blood transfusion is a classic sign of a transfusion reaction, specifically a transfusion-associated circulatory overload (TACO) or hemolytic reaction, both of which require immediate attention to prevent serious complications. Assessing this client first is crucial to ensure prompt intervention. Choices A, B, and D do not indicate immediate life-threatening complications and can be addressed after the client experiencing low back pain during a blood transfusion is stabilized.

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