Nursing Elites

1. The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines:

• A. human papillomavirus, genital herpes, measles.
• B. pneumonia, HIV, mumps.
• C. syphilis, gonorrhea, pneumonia.
• D. polio, pertussis, measles.

Correct answer: D

Rationale: Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases. The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the world's population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine childhood immunization. They have not, however, been eradicated, so children need to be immunized against these diseases. Choices A, B, and C contain vaccines that do not protect against preventable diseases like polio, pertussis, and measles. Therefore, the correct choice is D.

2. The charge nurse is observing a student nurse caring for a 4-month-old infant in isolation diagnosed with RSV. Which of the following would indicate to the charge nurse that the student nurse needs further instruction on isolation standards?

• A. Donning clean gloves each time she goes in the room.
• B. Wearing a clean mask each time she goes in the room.
• C. Labeling the door so staff will use Airborne Precautions.
• D. Wearing a gown when she goes in the room to administer medication.

Correct answer: A

Rationale: The correct answer is 'Donning clean gloves each time she goes in the room.' Sterile gloves are not necessary for standard isolation precautions; clean gloves are sufficient. The student nurse should be instructed to use clean gloves to reduce the risk of spreading infections. Wearing a clean mask each time she goes in the room is a good practice to prevent the spread of respiratory infections like RSV. Labeling the door for Airborne Precautions is appropriate for RSV. Wearing a gown when entering the room to administer medication helps prevent the transmission of infectious agents.

3. Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?

• A. open leg fracture
• B. open head injury
• C. stab wound to the chest
• D. traumatic amputation of a thumb

Correct answer: C

Rationale: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions. In this scenario, the stab wound to the chest poses the highest risk to the client's life as it can lead to severe complications such as lung collapse and mediastinal shift. Addressing this injury promptly is crucial to prevent further harm or potential fatality. Open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate life-threatening risk compared to a stab wound to the chest.

4. The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?

• A. Facial flushing
• B. A complaint of chest heaviness
• C. Heart rate increase of 10 beats/min
• D. Systolic blood pressure increase of 10 mm Hg

Correct answer: B

Rationale: The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced. Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.

5. Paula is a 32-year-old woman seeking evaluation and treatment for major depressive symptoms. A major nursing priority during the assessment process includes which of the following?

• A. meaning of current stressors
• B. possibility of self-harm
• C. motivation to participate in treatment
• D. presence of alcohol or other drug use

Correct answer: B

Rationale: The correct answer is to consider the possibility of self-harm during the assessment process. This is crucial because unless the client is first assessed for self-harm or suicide potential, the necessary degree of vigilance in the client's environment may not be observed. While understanding the meaning of current stressors is important for treatment planning, ensuring the client's safety takes precedence. Motivation to participate in treatment and the presence of alcohol or other drug use are also important aspects to assess but ensuring the client's safety is the top priority in this scenario.

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