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. What is the correct sequence for assessing the abdomen?

• A. Tympanic percussion, measurement of abdominal girth, and inspection
• B. Assessment for distention, tenderness, and discoloration around the umbilicus
• C. Percussion, palpation, and auscultation
• D. Auscultation, percussion, and palpation

Correct answer: D

Rationale: The correct sequence for assessing the abdomen is auscultation, percussion, and palpation. Auscultation allows the healthcare provider to listen for bowel sounds, followed by percussion to assess for areas of tenderness or abnormal distention, and finally palpation to feel for masses or organ enlargement. This sequence ensures a systematic and thorough assessment of the abdomen.

3. A client requests the creation of a living will. Which of the following actions should the nurse take?

• A. Schedule a meeting between the hospital ethics committee and the client.
• B. Evaluate the client's understanding of life-sustaining measures.
• C. Determine the client's preferences about post-mortem care.
• D. Request a conference with the client's family

Correct answer: B

Rationale: When a client requests the creation of a living will, the nurse's priority is to evaluate the client's understanding of life-sustaining measures. This involves ensuring that the client comprehends the implications of various life-sustaining interventions and can make informed decisions about their care preferences in the event they are unable to communicate them later. It is crucial for the nurse to assess the client's comprehension to ensure that the living will accurately reflects the client's wishes and values.

4. A client with tuberculosis is receiving a new prescription for isoniazid (INH). The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?

• A. You might notice yellowing of your skin.
• B. You might experience pain in your joints.
• C. You might notice tingling of your hands.
• D. You might experience loss of appetite.

Correct answer: C

Rationale: Tingling of the hands is a common adverse effect of isoniazid (INH) due to its potential to cause peripheral neuropathy. This sensation can be an early sign of nerve damage, and thus, the client should be instructed to report it promptly to the healthcare provider for further evaluation and management.

5. Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?

• A. Hemoglobinuria
• B. Chest pain
• C. Urticaria
• D. Distended neck veins

Correct answer: A

Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.

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