Nursing Elites

1. What should be done in order to prevent contamination of the environment when making a bed?

• A. Avoid flinging soiled linens
• B. Strip all linens at the same time
• C. Finish both sides at the same time
• D. Embrace soiled linen

Correct answer: A

Rationale: The correct practice to prevent contamination of the environment when making a bed is to avoid flinging soiled linens. Flinging soiled linens can spread contaminants in the environment, leading to potential health risks. By handling soiled linens properly and avoiding flinging them, the risk of contamination is minimized, ensuring a safer and cleaner environment. Stripping all linens at the same time (choice B) may not necessarily prevent contamination if the soiled linens are flung around. Finishing both sides at the same time (choice C) is unrelated to preventing contamination. Embracing soiled linen (choice D) is not hygienic and can lead to spreading contaminants.

2. A client has global aphasia affecting both receptive and expressive language abilities. Which intervention should NOT be included in the client's care plan?

• A. Speak to the client at a slower rate.
• B. Assist the client in using flash cards with pictures.
• C. Speak to the client in a loud voice.
• D. Give instructions one step at a time.

Correct answer: C

Rationale: Individuals with global aphasia have difficulty understanding and expressing language. Speaking loudly may not improve comprehension and can be perceived as aggressive. Therefore, it is important not to speak loudly to a client with global aphasia. Speaking at a slower rate, using visual aids like flash cards, and breaking down instructions into simple steps can facilitate communication and understanding for the client.

3. When teaching a client with tuberculosis, which statement should the nurse include?

• A. You will need to continue taking the multi-medication regimen for 4 months.
• B. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication.
• C. You will need to remain hospitalized for treatment.
• D. You will need to wear a mask at all times.

Correct answer: B

Rationale: Monitoring the effectiveness of tuberculosis medication is crucial to ensure the treatment is working properly. Regular sputum samples help in assessing the response to the medication. This monitoring can guide adjustments in the treatment plan if needed. Options A and C are incorrect as they do not reflect essential aspects of tuberculosis treatment. Option D is not a standard recommendation for tuberculosis treatment and may lead to misconceptions.

4. During the removal of a chest tube, what should the nurse instruct the client to do?

• A. Lie on their left side.
• B. Use the incentive spirometer.
• C. Cough at regular intervals.
• D. Perform the Valsalva maneuver.

Correct answer: D

Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.

5. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?

• A. Less than 30 ml/hour
• B. 64 ml in 2 hours
• C. 90 ml in 3 hours
• D. 125 ml in 4 hours

Correct answer: A

Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.

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