Nursing Elites

1. A client is lactose intolerant, and a nurse is reinforcing teaching. Which of the following statements should the nurse include?

• A. You should increase the fiber in your diet.
• B. You should increase the calories in your diet.
• C. You should decrease the dairy products in your diet.
• D. You should decrease the amount of vitamin D in your diet.

Correct answer: C

Rationale: The correct statement for a client who is lactose intolerant is to decrease dairy products since lactose intolerant individuals should avoid dairy to prevent symptoms like bloating, diarrhea, and gas. Increasing fiber (Choice A) or calories (Choice B) is not directly related to lactose intolerance. Decreasing vitamin D (Choice D) is not necessary as lactose intolerance is about the sugar in dairy, not vitamin D.

2. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

• A. Sensory perceptual alterations related to decreased vision
• B. Alteration in mobility related to fatigue
• C. Impaired gas exchange related to retained secretions
• D. Altered patterns of urinary elimination related to nocturia

Correct answer: D

Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.

3. The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?

• A. Stop the infusion
• B. Slow the rate of infusion
• C. Take vital signs and observe for further deterioration
• D. Administer Benadryl and continue the infusion

Correct answer: A

Rationale: In the scenario of a client developing urticaria during a blood transfusion, the immediate priority for the nurse is to stop the infusion. This action is crucial to prevent further administration of the allergen causing the reaction. Slowing the rate of infusion (Choice B) may not be sufficient to address the allergic response effectively. While monitoring vital signs (Choice C) is important, stopping the infusion takes precedence to prevent worsening of the reaction. Administering Benadryl (Choice D) should be considered after stopping the infusion, following the healthcare provider's orders, and assessing the client's condition.

4. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?

• A. Apply appropriate signs outside and inside the room
• B. Apply a mask with a shield if there is a risk of fluid splash
• C. Wear a gown to change soiled linens from incontinence
• D. Have gloves on while handling bedpans with feces

Correct answer: D

Rationale: The correct answer is to have gloves on while handling bedpans with feces. Hepatitis A is transmitted through the fecal-oral route, and using gloves during such direct contact with feces is crucial in preventing the transmission of the infection. Choice A is not directly related to infection control for hepatitis A. Choice B is more relevant to preventing droplet transmission rather than fecal-oral transmission. Choice C is important for preventing contact transmission from soiled linens but is not as directly related to the mode of transmission of hepatitis A as using gloves when handling feces.

5. A 20-year-old client has an infected leg wound from a motorcycle accident and has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:

• A. Visitors must wear a mask and a gown
• B. There are no special requirements for visitors of clients on contact precautions
• C. Visitors should wash their hands before and after touching the client
• D. Visitors -

Correct answer: C

Rationale: The correct answer is C: 'Visitors should wash their hands before and after touching the client.' When a client is on contact precautions, it is essential for visitors to practice good hand hygiene to prevent the spread of infection. While wearing a mask and a gown might be necessary for healthcare providers, it is not typically required for visitors. Option B is incorrect because there are indeed special requirements for visitors on contact precautions, including practicing good hand hygiene. Option D is incomplete and does not provide any guidance on infection prevention measures.

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