Nursing Elites

1. The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed?

• A. The child is placed in a private room
• B. The staff removes a toy from the child's bed and takes it to the nurse's station
• C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack
• D. The staff uses standard precautions

Correct answer: A

Rationale: The correct answer is A. Private room placement is crucial when caring for a patient with hepatitis A to prevent the transmission of the disease to others. Placing the child in a private room helps contain the infection and protect other patients and staff. Choices B, C, and D are incorrect because removing a toy from the child's bed, offering specific snacks, or using standard precautions, while important in general care, are not specific measures required to prevent the spread of hepatitis A.

2. In the emergency department, a nurse is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?

• A. Below-the-knee amputation.
• B. 10 cm (4 in) laceration.
• C. Fractured tibia.
• D. 95% full-thickness body burn.

Correct answer: A

Rationale: A below-the-knee amputation requires immediate attention due to the risk of hemorrhage and shock, making it the highest priority. This type of injury can lead to significant blood loss and impaired perfusion, which can be life-threatening if not addressed promptly. While a 10 cm laceration, a fractured tibia, and a 95% full-thickness body burn are serious injuries requiring urgent care, they do not pose the same immediate threat to life as a below-the-knee amputation. The laceration may require suturing to control bleeding and prevent infection, the fractured tibia needs stabilization to prevent further damage and pain, and the burn necessitates immediate management to prevent complications, but they are not as acutely life-threatening as the amputation.

3. A nurse is reviewing the plan of care for a client who is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent venous thromboembolism?

• A. Instruct the client to perform ankle pumps
• B. Administer anticoagulant therapy as prescribed
• C. Maintain the client in a prone position
• D. Encourage the client to ambulate as tolerated

Correct answer: B

Rationale: The correct intervention to prevent venous thromboembolism in a postoperative client following hip replacement is to administer anticoagulant therapy as prescribed. Anticoagulants help prevent blood clots from forming. Instructing the client to perform ankle pumps helps prevent blood clots by promoting circulation. Maintaining the client in a prone position can increase the risk of venous stasis and thrombus formation. Encouraging the client to ambulate as tolerated also helps prevent venous thromboembolism by promoting blood flow and preventing stasis.

4. A client with chronic obstructive pulmonary disease (COPD) is being taught by a nurse about measures to improve breathing. Which of the following instructions should the nurse include?

• A. Use pursed-lip breathing during physical activity
• B. Breathe deeply and quickly during exercise
• C. Avoid using the incentive spirometer
• D. Avoid physical activity to conserve energy

Correct answer: A

Rationale: The correct instruction the nurse should include is to 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a technique that helps improve breathing efficiency in individuals with COPD by preventing airway collapse and allowing for better air exchange. Choice B is incorrect because breathing deeply and quickly can lead to hyperventilation and worsen symptoms in COPD patients. Choice C is incorrect because the incentive spirometer is a device used to encourage deep breathing and improve lung function, so it should not be avoided. Choice D is incorrect because physical activity is important for maintaining overall health and should be encouraged in a controlled and appropriate manner for individuals with COPD.

5. A nurse is assisting with an in-service about hepatitis A for a group of staff nurses. The nurse should include that hepatitis A is transmitted through which of the following methods?

• A. Airborne droplets
• B. Sexual contact
• C. Contact with contaminated surfaces
• D. Consumption of contaminated food

Correct answer: D

Rationale: The correct answer is D: Consumption of contaminated food. Hepatitis A is primarily transmitted through the ingestion of contaminated food or water. Airborne droplets and sexual contact are not common modes of transmission for hepatitis A. While contact with contaminated surfaces can play a role in the spread of some infections, hepatitis A is not typically transmitted through this route.

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