Nursing Elites

1. Which is the most effective action for controlling the spread of infection?

• A. Thorough hand hygiene
• B. Wearing gloves and masks when providing direct client care
• C. Implementing appropriate isolation precautions
• D. Administering broad-spectrum prophylactic antibiotics

Correct answer: Thorough hand hygiene

Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.

2. An 86-year-old client with decreased visual acuity who uses a cane for mobility requires fall prevention education. What should the nurse teach this client to reduce the risk of falling at home?

• A. Take off shoes while in the house and wear only socks
• B. Limit activities to the lower level of the home
• C. Keep a lamp near the door of every room
• D. Install non-slip pads in the shower or bathtub

Correct answer: D: Install non-slip pads in the shower or bathtub

Rationale: To reduce the risk of falling at home for an elderly client with decreased visual acuity and using a cane for mobility, installing non-slip pads in the shower or bathtub is crucial. This measure helps prevent slips and falls in areas where water accumulation may occur. While taking off shoes and wearing socks may seem comfortable, it increases the risk of slipping. Limiting activities to the lower level of the home may restrict the client's independence and quality of life unnecessarily. Keeping a lamp near the door of every room may improve visibility but does not directly address the risk of falls associated with mobility and visual acuity issues.

3. When providing mouth care to a patient in a coma, what should you do to provide good and safe mouth care?

• A. keep the head of the bed up to prevent aspiration
• B. brush the teeth and rinse the mouth with a cup of water
• C. use a special foam swab to brush only the tongue
• D. use a special foam swab to brush the tongue and teeth

Correct answer: use a special foam swab to brush the tongue and teeth

Rationale: When providing mouth care to a patient in a coma, it is crucial to use a special foam swab to brush the tongue and teeth. This method helps maintain good oral hygiene for comatose patients. Special foam swabs are designed to effectively clean all areas of the mouth, including the cheeks and tongue, ensuring thorough care. Using water for mouth care in comatose patients can lead to aspiration, so it is important to avoid this practice. Keeping the head of the bed up alone does not prevent aspiration during mouth care for comatose patients, making choice A incorrect. Merely brushing the tongue (choice C) or using a foam swab only on the tongue (choice B) may not provide the comprehensive mouth care necessary for patients in a coma.

4. Who is the center of care?

• A. The doctor
• B. The administrator
• C. The patient
• D. The nurse

Correct answer: The patient

Rationale: The PATIENT is the center of care and the core of the healthcare team. The PATIENT holds the utmost importance within the healthcare setting. Healthcare professionals collaborate as a team to effectively address the needs of the patient. The primary focus should always be on the patient, who plays a crucial role in decision-making. While other healthcare team members, such as doctors, nurses, and administrators, play vital roles, the patient remains the central figure. The patient has the fundamental right to receive quality care from all members of the healthcare team.

5. The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?

• A. Client will be able to turn self by day 3
• B. Skin will remain intact and without redness during hospital stay
• C. Client will state pain relieved within 30 minutes after medication
• D. Pressure will be prevented by repositioning client every 2 hours

Correct answer: Skin will remain intact and without redness during hospital stay

Rationale: The correct desired outcome for a nursing diagnosis of 'Risk for impaired skin integrity' is to ensure that the skin remains intact and without redness during the hospital stay. This outcome directly addresses the risk identified in the diagnosis. Option A focuses on addressing immobility, which is not the priority for this diagnosis. Option C deals with pain relief, which is a separate concern. Option D is an intervention involving pressure prevention through repositioning, rather than an outcome related to skin integrity.

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