Nursing Elites

1. The nurse is providing care for a client with a draining postoperative wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which is the most important action for the nurse to take?

• A. Encourage increased oral fluids.
• B. Provide high-protein snacks.
• C. Change the wound dressing.
• D. Administer prescribed antibiotics.

Correct answer: D

Rationale: Administering prescribed antibiotics is crucial in treating MRSA infections. MRSA is a type of bacteria that is resistant to many antibiotics, including methicillin. Therefore, prompt administration of the appropriate antibiotics is essential to target the MRSA infection effectively. Encouraging increased oral fluids (Choice A) and providing high-protein snacks (Choice B) may be beneficial for overall recovery but are not the most important actions in treating an MRSA infection. Changing the wound dressing (Choice C) is important for wound care but does not directly address the infection caused by MRSA.

2. The nurse is in charge of a Nursing unit in a long-term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients?

• A. Measure the amount of a client's residual urine after voiding
• B. Cleanse the perineal area of a client with urinary incontinence
• C. Insert a straight catheter to obtain a urine specimen for culture
• D. Provide catheter care for a client with a suprapubic catheter

Correct answer: B

Rationale: The correct answer is B because cleaning the perineal area is a task within the scope of practice for unlicensed assistive personnel (UAPs) and is crucial for preventing infections. Choice A involves a more complex task that requires a healthcare provider's assessment. Choice C involves a sterile procedure that should be performed by licensed staff. Choice D involves specific care for a client with a catheter that exceeds the UAP's scope of practice.

3. The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage?

• A. Place a 4x4 wick in the stoma opening
• B. Apply a layer of zinc oxide ointment to the perimeter of the stoma
• C. Cut the bag opening to the measurement of the stoma size
• D. Administer a PRN antidiarrheal agent

Correct answer: C

Rationale: To prevent leakage of stool under the disposable ostomy bag, the nurse should cut the bag opening to the measurement of the stoma size. This action ensures a proper fit, which is crucial in preventing leaks that can lead to skin irritation and compromise stoma care. Placing a 4x4 wick in the stoma opening or applying zinc oxide ointment may not address the issue of leakage effectively. Administering a PRN antidiarrheal agent is not directly related to preventing leakage caused by an ill-fitting ostomy bag.

4. The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding. What information should the nurse provide this client?

• A. The client should bottle feed and pump her breast for 3 days following immunization
• B. The vaccine is given to produce maternal antibodies before lactation occurs
• C. The infant will receive immunization through the mother's breast milk
• D. The client should not get pregnant for 3 months after immunization

Correct answer: D

Rationale: Educating about the waiting period helps prevent possible rubella infection in a subsequent early pregnancy.

5. When caring for a client with a tracheostomy, what is the most important assessment to perform?

• A. Check the client's oxygen saturation
• B. Assess the tracheostomy site for signs of infection
• C. Monitor the client's respiratory rate
• D. Ensure the tracheostomy ties are secure

Correct answer: A

Rationale: The most important assessment to perform when caring for a client with a tracheostomy is to check the client's oxygen saturation. This assessment is crucial as it ensures that the client is receiving adequate oxygen through the tracheostomy. Monitoring oxygen saturation provides immediate information on the client's respiratory status and the effectiveness of the airway management. Assessing the tracheostomy site for signs of infection is important but not as critical as ensuring adequate oxygenation. Monitoring the respiratory rate is also essential but does not directly assess the effectiveness of oxygenation. Ensuring tracheostomy ties are secure is important for maintaining the device but does not directly evaluate the client's oxygenation status.

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