Nursing Elites

1. Which intervention should the nurse include in the plan of care for a patient with tetanus?

• A. Open window shades to provide natural light
• B. Encourage coughing and deep breathing
• C. Minimize the amount of stimuli in the room
• D. Reposition from side to side every hour

Correct answer: C

Rationale: The correct intervention for a patient with tetanus is to minimize the amount of stimuli in the room. Tetanus can lead to muscle spasms and heightened sensitivity to stimuli, making it essential to reduce environmental triggers for the patient's comfort and safety. Opening window shades for natural light (Choice A) may exacerbate sensitivity to light and worsen symptoms. Encouraging coughing and deep breathing (Choice B) is not directly related to managing tetanus symptoms. While repositioning the patient every hour (Choice D) is important for preventing pressure ulcers, it is not the priority when managing tetanus, which requires a quiet, low-stimulus environment to minimize muscle spasms and discomfort.

2. In what order should the nurse perform the steps of a surgical hand scrub prior to entering the operating room?

• A. Rinse from the fingertips to the elbow
• B. Scrape under the nails with a nail pick
• C. Use a soapy brush to scrub the hands
• D. Cleanse the arm with a lathered brush

Correct answer: B

Rationale: The correct order for performing a surgical hand scrub is to first scrape under the nails with a nail pick, then scrub the hands using a soapy brush, cleanse the arms, and finally rinse. This sequence ensures thorough cleaning and minimizes the risk of contamination. Choice A is incorrect because rinsing should be the final step, not the first. Choice C is incorrect as scrubbing the hands comes after scraping under the nails. Choice D is incorrect as cleansing the arms should follow hand scrubbing, not precede it.

3. A client with active tuberculosis (TB) is receiving isoniazid (INH) and rifampin (RMP) daily, so direct observation therapy (DOT) is initiated while the client is hospitalized. Which instruction should the nurse provide this client?

• A. Describe feelings about taking daily medications
• B. Take medications in the presence of the nurse
• C. Notify the nurse after self-medication is completed
• D. Keep a daily record of all medications taken

Correct answer: B

Rationale: The correct instruction for the nurse to provide the client undergoing direct observation therapy for TB is to take medications in the presence of the nurse. This approach ensures that the client is actually taking the medications as prescribed, reducing the risk of noncompliance. Choice A is incorrect because the focus should be on ensuring the client physically takes the medications rather than discussing feelings. Choice C is incorrect as it does not ensure direct observation. Choice D is incorrect because self-reporting or keeping a record does not guarantee that the client is actually taking the medications.

4. What action should the nurse take after a client produces the first of a series of sputum samples for cytology?

• A. Ensure the client remains NPO until all samples are collected
• B. Transport the sputum container to the laboratory in a biohazard bag
• C. Discard the initial sample and document the time it was obtained
• D. Document the time the client last ate or drank on the laboratory slip

Correct answer: B

Rationale: The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.

5. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him feel bad. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Stroke secondary to hemorrhage
• B. Acute kidney injury due to glomerular damage
• C. Heart block due to myocardial damage
• D. Blindness secondary to cataracts

Correct answer: A

Rationale: The correct answer is A: Stroke secondary to hemorrhage. Hypertension increases the risk of stroke due to the stress and damage it causes to blood vessels, which can lead to hemorrhage. Choice B is incorrect because acute kidney injury is more commonly associated with chronic uncontrolled hypertension, not acute elevations. Choice C is incorrect as heart block is not a direct consequence of hypertension. Choice D is incorrect as hypertension does not directly cause cataracts leading to blindness.

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