Nursing Elites

1. A nurse is teaching a client who is undergoing chemotherapy about measures to prevent infection. Which of the following instructions should the nurse include?

• A. Avoid crowded places
• B. Wear a mask at home
• C. Drink unfiltered water
• D. Avoid washing hands frequently

Correct answer: A

Rationale: The correct instruction the nurse should include is to advise the client to avoid crowded places. Immunocompromised clients undergoing chemotherapy are at a higher risk of infections, so avoiding crowded places can help reduce exposure to pathogens. Wearing a mask at home is not necessary unless someone in the household is sick. Drinking unfiltered water can introduce harmful bacteria, increasing the risk of infection. Avoiding washing hands frequently is incorrect as hand hygiene is crucial in preventing the spread of infections.

2. A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Elevated blood pressure.
• C. Furrows in the tongue.
• D. Polyuria.

Correct answer: C

Rationale: The correct answer is C: 'Furrows in the tongue.' Dehydration commonly presents with furrows in the tongue due to decreased oral moisture. This physical finding indicates dehydration as the tongue loses moisture and becomes dry. Choice A, 'Bradycardia,' is not typically associated with dehydration; instead, tachycardia may be present as a compensatory mechanism. Elevated blood pressure, as mentioned in choice B, is not a typical finding in dehydration; in fact, dehydration often leads to a decrease in blood pressure. Polyuria, as in choice D, is more commonly associated with conditions like diabetes mellitus or diabetes insipidus, rather than dehydration.

3. A client with a pressure ulcer is being cared for by a nurse. Which of the following is the most appropriate action?

• A. Use a phenol solution to clean the wound
• B. Place a warm compress over the wound
• C. Cleanse the wound from the center outwards
• D. Administer antibiotics prophylactically

Correct answer: C

Rationale: Cleaning a wound from the center outwards is the most appropriate action as it helps prevent the spread of infection. Choice A is incorrect as phenol solutions can be harmful to the wound and delay healing. Choice B may increase the risk of infection as warmth can promote bacterial growth. Choice D is unnecessary unless there are signs of infection present.

4. What are the key signs of hyperglycemia?

• A. Increased thirst and frequent urination
• B. Decreased appetite and low blood pressure
• C. Weight loss and nausea
• D. Increased sweating and confusion

Correct answer: A

Rationale: The correct answer is A: Increased thirst and frequent urination. These are classic signs of hyperglycemia, indicating elevated blood sugar levels. Choice B is incorrect as hyperglycemia usually presents with increased appetite rather than decreased appetite and low blood pressure. Choice C is incorrect as weight loss is more commonly associated with uncontrolled diabetes rather than hyperglycemia. Choice D is incorrect as increased sweating and confusion are not typical signs of hyperglycemia.

5. A client with a tracheostomy is experiencing increased secretions and labored breathing. What should the nurse do first?

• A. Administer a bronchodilator
• B. Suction the tracheostomy
• C. Encourage the client to cough
• D. Notify the provider

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy first. When a client with a tracheostomy is experiencing increased secretions and labored breathing, suctioning the tracheostomy is the priority intervention to clear the airway and improve breathing. Administering a bronchodilator (Choice A) may help with breathing but should come after ensuring the airway is clear. Encouraging the client to cough (Choice C) may not be effective in clearing secretions from the tracheostomy. Notifying the provider (Choice D) can be done after ensuring immediate airway clearance.

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