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. A client with a history of seizures is being discharged home. Which instruction is most important for the nurse to provide?

• A. Take your medication as prescribed.
• B. Avoid driving until your condition is stable.
• C. Keep a seizure diary.
• D. Avoid alcohol consumption.

Correct answer: A

Rationale: The most important instruction for a client with a history of seizures being discharged home is to take their medication as prescribed. Consistent and timely intake of anti-seizure medication is vital in managing seizures and preventing episodes. While instructions like avoiding driving until the condition is stable, keeping a seizure diary, and avoiding alcohol consumption are important, none are as critical as ensuring proper medication adherence to control seizures effectively. Failure to take prescribed medications can lead to breakthrough seizures, compromising the patient's safety and seizure control.

3. A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.)

• A. Portal hypertension.
• B. Sodium and water retention.
• C. Decreased serum albumin.
• D. All of the above

Correct answer: D

Rationale: In advanced liver failure related to chronic alcoholism, ascites and edema occur due to multiple pathophysiological mechanisms. Portal hypertension contributes to the development of ascites by increasing pressure in the portal venous system. Sodium and water retention exacerbate fluid accumulation in the third space. Decreased serum albumin levels lead to reduced oncotic pressure, contributing to the movement of fluid into the interstitial spaces. Abnormal protein metabolism further disrupts fluid balance. Therefore, all of the options (A, B, and C) are correct in this scenario, making choice D the correct answer. Choices A, B, and C alone do not fully explain the comprehensive pathophysiological mechanisms involved in the development of ascites and edema in this clinical context.

4. Which membrane lines the abdominal cavity?

• A. Perineum
• B. Pericardium
• C. Pleura
• D. Peritoneum

Correct answer: D

Rationale: The correct answer is D, Peritoneum. The peritoneum is the membrane that lines the abdominal cavity, providing support to abdominal organs and serving as a conduit for their blood vessels. Choices A, B, and C are incorrect. The perineum refers to the area between the anus and the external genitalia, the pericardium is the membrane enclosing the heart, and the pleura is the membrane surrounding the lungs.

5. A client is admitted with a diagnosis of congestive heart failure (CHF). Which intervention is most important to include in the plan of care?

• A. Restrict fluid intake
• B. Provide a high-sodium diet
• C. Encourage vigorous exercise
• D. Administer bronchodilators as prescribed

Correct answer: A

Rationale: The correct answer is A: Restrict fluid intake. Fluid restriction is crucial in the management of congestive heart failure (CHF) as it helps prevent fluid overload, which can exacerbate CHF symptoms. Choices B, C, and D are incorrect. Providing a high-sodium diet would worsen fluid retention and increase the workload of the heart. Encouraging vigorous exercise can strain the heart further in CHF patients. Administering bronchodilators is not the priority intervention for CHF.

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