Nursing Elites

1. A nurse manager is discussing the responsibility of nurses caring for clients who have Clostridium 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 a client with Clostridium difficile is essential to prevent the spread of infection. Options A, B, and C are incorrect. Negative air-flow systems are not necessary for preventing the spread of C. difficile. While alcohol-based hand sanitizers are effective for routine hand hygiene, they may not be sufficient for C. difficile. Cleaning contaminated surfaces with a phenol solution is not the most effective method for preventing the spread of C. difficile, as spores can be resistant to many disinfectants.

2. A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following instructions should the nurse include?

• A. Use abdominal breathing during physical activity
• B. Inhale quickly and deeply through the nose
• C. Use pursed-lip breathing during physical activity
• D. Breathe quickly and deeply during exercise

Correct answer: C

Rationale: The correct answer is C: 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a beneficial technique for clients with COPD as it helps improve airflow by keeping the airways open longer. Choice A is incorrect as abdominal breathing may not be as effective in COPD as pursed-lip breathing. Choice B, inhaling quickly and deeply through the nose, is not recommended as it can lead to hyperventilation. Choice D, breathing quickly and deeply during exercise, is also not suitable for clients with COPD as it can cause increased shortness of breath.

3. When caring for a client with a wound infection, what is the most important nursing action?

• A. Change the dressing every 4 hours
• B. Perform a wound culture before administering antibiotics
• C. Cleanse the wound with alcohol-based solutions
• D. Apply a wet-to-dry dressing to the wound

Correct answer: B

Rationale: Performing a wound culture before administering antibiotics is crucial in identifying the specific infecting organism and choosing the most effective antibiotic treatment. Changing the dressing every 4 hours (choice A) may be too frequent and can disrupt the wound healing process. Cleansing the wound with alcohol-based solutions (choice C) can be too harsh and may delay healing. Applying a wet-to-dry dressing (choice D) can cause trauma to the wound bed and is not recommended for infected wounds.

4. A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. Hemoglobin A1c of 6%
• B. Fasting blood glucose of 90 mg/dL
• C. Blood glucose of 200 mg/dL
• D. Blood glucose of 100 mg/dL

Correct answer: C

Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.

5. Which of the following interventions is the best to improve the healing of a pressure ulcer for a client with a low serum albumin level?

• A. Provide high-calorie, high-protein supplements
• B. Consult a dietitian to create a high-protein diet plan
• C. Administer nutritional supplements
• D. Increase IV fluids to prevent dehydration

Correct answer: B

Rationale: Consulting a dietitian to create a high-protein diet plan is the best intervention for a client with a low serum albumin level to promote healing. This approach ensures that the client receives the specific nutrients needed for wound healing. Providing high-calorie, high-protein supplements (choice A) may not address the specific nutritional deficiencies of the client. Administering nutritional supplements (choice C) is vague and may not target the necessary nutrients for wound healing. Increasing IV fluids (choice D) is important for hydration but does not directly address the nutritional needs of the client to improve ulcer healing.

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