Nursing Elites

1. What is the priority intervention for sepsis?

• A. Administer IV antibiotics
• B. Monitor blood pressure
• C. Administer fluids
• D. All of the above

Correct answer: D

Rationale: In the management of sepsis, prompt intervention is crucial. Administering IV antibiotics is essential to target the underlying infection. Monitoring blood pressure helps assess the patient's hemodynamic status. Administering fluids is vital to maintain adequate perfusion. Therefore, all the options are integral components of the initial management of sepsis, making 'All of the above' the correct answer. Choosing any single intervention over the others may delay optimal care and compromise patient outcomes.

2. When providing discharge instructions for a client with home oxygen, what safety measure should the nurse emphasize?

• A. Prohibit smoking near oxygen equipment
• B. Ensure the client uses non-flammable bedding
• C. Ensure oxygen tanks are stored upright
• D. Keep the oxygen equipment at least 6 feet away from heat sources

Correct answer: D

Rationale: The correct answer is to keep the oxygen equipment at least 6 feet away from heat sources. Placing oxygen equipment near heat sources can lead to fire hazards due to the oxygen's combustible nature. Option A is the correct safety measure as smoking near oxygen equipment can cause fires due to oxygen's flammable properties. Option B regarding the use of non-flammable bedding is not directly related to oxygen safety. Option C is important for proper oxygen tank functioning but is not as critical as keeping the equipment away from heat sources to prevent fires.

3. A client receiving chemotherapy has developed stomatitis. Which of the following actions should the nurse take?

• A. Provide lemon-glycerin swabs
• B. Encourage the client to eat soft foods
• C. Avoid using toothpaste
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with stomatitis due to chemotherapy is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the already inflamed and sore oral mucosa. Providing lemon-glycerin swabs may further irritate the mucosa due to the acidic nature of lemon. Avoiding toothpaste is advisable as many toothpaste products contain ingredients that can aggravate stomatitis. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol-based mouthwashes can be too harsh and drying for the already sensitive oral tissues.

4. A nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which of the following information should the nurse include?

• A. Frequent hand washing prevents infection
• B. Prolonged use of corticosteroids increases infection risk
• C. Limit patient interaction to reduce infection spread
• D. Restrict client movement to prevent contamination

Correct answer: B

Rationale: The correct answer is B because prolonged use of corticosteroids is a known risk factor for infections. Choice A is incorrect because frequent hand washing actually helps prevent infections. Choice C is incorrect as patient interaction is essential in healthcare but should be done following proper infection control measures. Choice D is also incorrect as restricting client movement is not a standard practice to prevent contamination.

5. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate (TURP). Which of the following should the nurse identify as a priority nursing assessment after reviewing the client's information?

• A. Level of consciousness.
• B. Skin turgor.
• C. Deep-tendon reflexes.
• D. Bowel sounds.

Correct answer: A

Rationale: The correct answer is A: Level of consciousness. Following a TURP procedure, monitoring the client's level of consciousness is crucial as it can indicate potential postoperative complications such as hemorrhage or shock. Skin turgor (choice B) is more related to hydration status, deep-tendon reflexes (choice C) are not the priority post-TURP, and bowel sounds (choice D) are important but not the priority in this situation.

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