Nursing Elites

1. Which action should the PN implement when using standard precautions to provide client care?

• A. Apply sterile gloves to obtain a finger stick blood sample
• B. Wear clean exam gloves to perform perineal catheter care
• C. Replace the needle cap after giving an intramuscular injection
• D. Wear a paper gown to prevent transmission of droplet pathogens

Correct answer: B

Rationale: The correct answer is B. When using standard precautions, healthcare providers should wear clean exam gloves to perform perineal catheter care. This approach helps prevent the transmission of pathogens and ensures the safety of both the client and the healthcare provider. Choice A is incorrect because applying sterile gloves for a finger stick blood sample is unnecessary when non-sterile gloves would suffice. Choice C is incorrect because replacing the needle cap after giving an intramuscular injection is not directly related to standard precautions. Choice D is incorrect because wearing a paper gown is not a standard precaution for preventing the transmission of droplet pathogens.

2. How does the home care nurse determine that a 78-year-old client is unable to remain in his current residence alone?

• A. The goals set by the client
• B. The learning level of the client
• C. Assessing the home environment
• D. The distractions in the client's home

Correct answer: C

Rationale: The correct answer is assessing the home environment. This process is vital in evaluating whether an elderly client can safely live independently. Factors like safety hazards and the client's ability to handle daily activities are considered during this assessment. Choices A, B, and D are incorrect because determining the client's ability to remain in his residence alone relies more on evaluating the home environment for safety and suitability rather than the client's goals, learning level, or distractions in the home.

3. A client presents to the office with complaints of swelling in the legs, chills, and shortness of breath. During auscultation of the chest, a heart murmur is heard. The client's blood culture reveals a microorganism in the blood. When a microorganism is found in the blood, this condition is called

• A. Bacteremia
• B. Sepsis
• C. Septicemia
• D. Parasitic infection

Correct answer: A

Rationale: When a microorganism is found in the blood, this condition is called bacteremia, which refers to the presence of bacteria in the bloodstream, as indicated by a positive blood culture. If not appropriately treated, bacteremia can progress to septicemia, also known as sepsis. Sepsis is a severe and life-threatening response to an infection, characterized by systemic inflammation and organ dysfunction. Parasitic infections involve pathogens other than bacteria and are not directly related to the scenario described.

4. What is the primary purpose of administering Rho(D) immune globulin (RhoGAM) to an Rh-negative mother after childbirth?

• A. To prevent Rh sensitization in future pregnancies
• B. To treat anemia in the newborn
• C. To increase the mother's white blood cell count
• D. To prevent infection in the newborn

Correct answer: A

Rationale: The correct answer is A: To prevent Rh sensitization in future pregnancies. RhoGAM is given to an Rh-negative mother to prevent the development of antibodies against Rh-positive blood cells. This prevents Rh sensitization, which could lead to hemolytic disease in future Rh-positive pregnancies. Choices B, C, and D are incorrect because RhoGAM is not used to treat anemia in the newborn, increase the mother's white blood cell count, or prevent infection in the newborn.

5. A male client who has been diagnosed with schizophrenia is withdrawn, isolates himself in the day room, and answers questions with one or two-word responses. This morning, the practical nurse observes that he is diaphoretic and is pacing in the hall. Which intervention is most important for the PN to implement?

• A. Persuade the client to lie down
• B. Provide a drink high in electrolytes
• C. Observe the client during the shift
• D. Measure appropriate vital signs

Correct answer: D

Rationale: Measuring vital signs is crucial in this situation as it helps to determine if the client is experiencing a physical health issue or if the symptoms are related to a mental health crisis, such as anxiety or agitation. The presence of diaphoresis and pacing may indicate physiological changes requiring immediate attention. Providing a drink high in electrolytes or persuading the client to lie down may not address the underlying cause of the symptoms. Simply observing the client during the shift without taking necessary actions to assess his physiological status may delay appropriate intervention.

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