Nursing Elites

1. The nurse is caring for a client with a central venous catheter. What is the most important action for the nurse to take to prevent infection?

• A. Change the catheter dressing every 72 hours.
• B. Flush the catheter with heparin solution daily.
• C. Ensure the catheter is clamped when not in use.
• D. Maintain sterile technique when handling the catheter.

Correct answer: D

Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. Changing the catheter dressing every 72 hours, while important for overall catheter care, does not directly address infection prevention. Flushing the catheter with heparin solution daily is essential for maintaining patency but does not primarily prevent infections. Ensuring the catheter is clamped when not in use is important for preventing air embolism but is not the most critical action to prevent infection. The most effective way to prevent infections is by strictly adhering to sterile techniques during catheter handling, which minimizes the risk of introducing pathogens into the catheter site.

2. Which nursing action prevents injury to a client's eye during the administration of eye drops?

• A. Holding the tip of the container above the conjunctival sac
• B. Rinsing the eye with saline before administration
• C. Placing the client in a supine position
• D. Pressing gently on the lower eyelid to open the eye

Correct answer: A

Rationale: The correct nursing action to prevent injury to a client's eye during the administration of eye drops is to hold the tip of the container above the conjunctival sac. This technique helps to prevent direct contact between the container and the eye, reducing the risk of injury. Rinsing the eye with saline before administration (Choice B) is not a standard practice and may not necessarily prevent injury. Placing the client in a supine position (Choice C) is not directly related to preventing eye injury during eye drop administration. Pressing gently on the lower eyelid to open the eye (Choice D) is not recommended as it can potentially cause injury or discomfort to the client.

3. A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?

• A. Obtain a perception from the healthcare provider regarding visitation privileges
• B. Request a consultation with the ethics committee for resolution of the situation
• C. Encourage the client to speak with her husband regarding his disruptive behavior
• D. Communicate the client's wishes to all members of the multidisciplinary team

Correct answer: D

Rationale: The correct intervention is to communicate the client's wishes to all members of the multidisciplinary team. This action respects the client's autonomy and maintains her comfort by ensuring that her desires regarding visitation and support are known and upheld. Obtaining a perception from the healthcare provider regarding visitation privileges (Choice A) may not fully consider the client's preferences. Requesting a consultation with the ethics committee (Choice B) may be premature and could delay prompt resolution of the issue. Encouraging the client to speak with her husband (Choice C) may not be appropriate, as the husband's demands are disrupting the client's care and comfort, and the client may not feel safe or comfortable doing so.

4. A client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

• A. Droplet
• B. Contact
• C. Airborne
• D. Protective

Correct answer: A

Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.

5. A client with a terminal illness is expected to pass away within 24 hours. The family asks the nurse about what to expect at this time. Which of the following findings should the nurse include?

• A. Regular breathing pattern
• B. Warm extremities
• C. Increased urine output
• D. Decreased muscle tone

Correct answer: D

Rationale: As death approaches, decreased muscle tone and other signs like decreased blood pressure, irregular breathing patterns, cold extremities, and decreased urine output are common. Warm extremities (choice B) would not be expected as circulation may be compromised. Increased urine output (choice C) is unlikely as organ function declines. A regular breathing pattern (choice A) is also unlikely as irregular breathing patterns are common near death.

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