Nursing Elites

1. Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?

• A. Wearing clean gloves while performing a heel stick on an infant
• B. Wearing the same gloves for assessments of clients in the same room
• C. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client
• D. Donning a gown when responding to a request by the family to check the IV pump on a client with rotavirus

Correct answer: A

Rationale: The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile. Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions. Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks. Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.

2. The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?

• A. Assist the client to a sitting position at the edge of the bed
• B. Have the client march in place for 30 seconds
• C. Have the client raise his arms above his head
• D. Ask the client the last time he fell

Correct answer: A

Rationale: The correct action to perform before ambulating a client post total knee replacement is to assist the client to a sitting position at the edge of the bed. This step is crucial to prevent orthostatic hypotension and ensure the client is ready to stand and walk safely. Having the client march in place or raise his arms above his head are not necessary preparations for ambulation. While knowing about the client's fall history is important for safety reasons, it is not the priority action immediately before ambulating the client.

3. What is the drug of choice for herpes simplex virus 1, herpes simplex virus 2, and varicella-zoster virus?

• A. HIV.
• B. HSV 1, HSV 2, and VZV.
• C. CMV
• D. Influenza A viruses.

Correct answer: B

Rationale: Acyclovir (Zovirax) is the drug of choice for herpes simplex virus 1 (HSV-1), herpes simplex virus 2 (HSV-2), and varicella-zoster virus (VZV) infections. It works by inhibiting viral DNA replication. Acyclovir is excreted unchanged in the urine, so caution is needed in renal impairment. Choice A, HIV, is incorrect as acyclovir is not the drug of choice for HIV. Choice C, CMV, is incorrect as acyclovir is not the preferred treatment for cytomegalovirus (CMV) infections. Choice D, Influenza A viruses, is incorrect as acyclovir is not used to treat influenza viruses.

4. The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice until the client regains full consciousness?

• A. Supine
• B. Fowlers
• C. Lateral
• D. High Fowlers

Correct answer: C

Rationale: The correct answer is 'Lateral.' When a client is very drowsy or sedated, placing them in the lateral position is important to maintain an open airway and allow for drainage of secretions. This position helps prevent airway obstruction and aspiration. Choice A, 'Supine,' is lying flat on the back and may not be ideal for a drowsy client due to the risk of airway compromise. Choice B, 'Fowlers,' is a semi-sitting position that is beneficial for clients with respiratory distress, but it may not be the best choice for a very drowsy individual. Choice D, 'High Fowlers,' is a more upright sitting position, which again may not be suitable for a drowsy client as it does not facilitate airway patency as effectively as the lateral position.

5. The nurse is caring for a client with hyperemesis gravidarum. What is the most likely electrolyte imbalance?

• A. Hypocalcemia
• B. Hypomagnesemia
• C. Hyponatremia
• D. Hypokalemia

Correct answer: D

Rationale: In hyperemesis gravidarum, where the client experiences severe nausea and vomiting, the most likely electrolyte imbalance is hypokalemia. Potassium is abundant in the stomach, and excessive vomiting leads to potassium loss. Hypocalcemia (Choice A) is not typically associated with hyperemesis gravidarum. Hypomagnesemia (Choice B) and Hyponatremia (Choice C) are less likely to occur compared to hypokalemia in this condition.

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