Nursing Elites

1. When reassigned to the emergency department, a nurse should understand that gastric lavage is a priority in which situation?

• A. An infant who has been identified to have botulism
• B. A toddler who ate a number of ibuprofen tablets
• C. A preschooler who swallowed powdered plant food
• D. A school-aged child who took a handful of vitamins

Correct answer: A

Rationale: The correct answer is A because gastric lavage is a priority for infants with botulism to remove toxins from the stomach. Botulism is a serious condition caused by a toxin produced by Clostridium botulinum bacteria. Gastric lavage helps in removing the toxin from the stomach. Choice B is incorrect because gastric lavage is not typically indicated for ibuprofen ingestion. Choice C is incorrect because gastric lavage is not the first-line treatment for ingesting powdered plant food. Choice D is incorrect because gastric lavage is not routinely performed for vitamin ingestion.

2. The healthcare provider is assessing a client who has just returned from surgery. Which of these findings requires the most immediate attention?

• A. Respiratory rate of 16 breaths per minute
• B. Blood pressure of 120/80 mm Hg
• C. Temperature of 99.5 degrees Fahrenheit
• D. Heart rate of 80 beats per minute

Correct answer: C

Rationale: A temperature of 99.5 degrees Fahrenheit is slightly elevated but not immediately critical. In a postoperative patient, an elevated temperature could indicate an infection, which requires prompt attention to prevent complications. The respiratory rate, blood pressure, and heart rate within normal ranges are important to monitor but do not indicate an immediate need for intervention as an elevated temperature does.

3. A client is diagnosed with methicillin-resistant Staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

• A. Reverse
• B. Airborne
• C. Standard precautions
• D. Contact

Correct answer: D

Rationale: The correct answer is 'D: Contact.' Contact precautions are necessary for clients with MRSA pneumonia to prevent the spread of the resistant bacteria. MRSA is primarily spread by direct contact, so using contact precautions, such as wearing gloves and gowns, is essential. Choice A, 'Reverse,' is not a type of isolation precaution. Choice B, 'Airborne,' is not the appropriate isolation for MRSA pneumonia, as MRSA is not transmitted through the airborne route. Choice C, 'Standard precautions,' are important for all clients, but for MRSA pneumonia specifically, contact precautions are more targeted and necessary.

4. Which bed position is preferred for use with a client in an extended care facility on a falls risk prevention protocol?

• A. All 4 side rails up, wheels locked, bed closest to door
• B. Lower side rails up, bed facing the doorway
• C. Knees bent, head slightly elevated, bed in the lowest position
• D. Bed in the lowest position, wheels locked, place bed against the wall

Correct answer: D

Rationale: The correct answer is D. Placing the bed in the lowest position, ensuring wheels are locked, and positioning it against the wall is the preferred bed position for a client in an extended care facility on a falls risk prevention protocol. This setup helps minimize the risk of falls by providing a stable and secure environment. Choices A, B, and C do not address key factors such as having the bed in the lowest position and placing it against the wall, which are crucial in preventing falls in such a setting.

5. During the care of a client with a salmonella infection, what is the primary nursing intervention to limit transmission?

• A. Wash hands thoroughly before and after client contact
• B. Wear gloves when in contact with body secretions
• C. Double glove when in contact with feces or vomitus
• D. Wear gloves when disposing of contaminated linens

Correct answer: A

Rationale: The correct answer is to wash hands thoroughly before and after client contact when caring for a client with a salmonella infection. This approach is crucial in preventing the transmission of the infection. While wearing gloves when in contact with body secretions (Choice B), double gloving when in contact with feces or vomitus (Choice C), and wearing gloves when disposing of contaminated linens (Choice D) are important infection control measures, the primary intervention to limit the spread of salmonella is proper hand hygiene.

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