Nursing Elites

1. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?

• A. Mode of transmission
• B. Portal of entry
• C. Reservoir
• D. Portal of exit

Correct answer: A

Rationale: When the nurse rolls contaminated gloves inside-out, they are manipulating the mode of transmission in the chain of infection. The gloves, which are contaminated, act as a vehicle for transferring pathogens from the reservoir's portal of exit to a potential portal of entry. Choices B, C, and D are incorrect because the action of rolling contaminated gloves does not directly relate to the portal of entry, reservoir, or portal of exit in the chain of infection.

2. The client has a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy?

• A. Mastery of colostomy care techniques
• B. Readiness to accept an altered body function
• C. Awareness of community resources available
• D. Understanding necessary dietary modifications

Correct answer: B

Rationale: The most crucial client outcome for successful adjustment to a new colostomy is the readiness to accept an altered body function. Acceptance of changes in body image and function is essential to facilitate mastery of colostomy care techniques and optimal utilization of community resources. Without readiness to accept the altered body function, the client may not be open to learning and adopting necessary changes, hindering the achievement of long-term goals. Understanding dietary modifications, while important, is secondary to the fundamental acceptance of the altered body function in the process of adjusting to a new colostomy.

3. The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?

• A. Determine how well the client can change the dressing.
• B. Ask the client to demonstrate the procedure.
• C. Seek a family member's opinion on the client's dressing change ability.
• D. Observe the client change the dressing unassisted.

Correct answer: D

Rationale: The best method for the nurse to evaluate the client's ability to perform a dressing change at home is by observing the client change the dressing unassisted. Direct observation allows the nurse to assess if the client has mastered the skill and provides an opportunity to confirm the proficiency. Options A, B, and C do not offer the same level of assessment as direct observation. Option A incorrectly focuses on the client's feelings rather than their actual performance ability. Option B, asking the client to demonstrate the procedure, may not accurately reflect their practical skills. Option C, seeking a family member's opinion, introduces potential bias and may not provide an accurate assessment of the client's ability to perform the dressing change independently.

4. What is the best intervention for a client with borderline personality disorder?

• A. Establishing clear boundaries
• B. Exploring vocational possibilities
• C. Discussing feelings of victimization
• D. Spending 1 to 2 hours per day with the client

Correct answer: A

Rationale: The best intervention for a client with borderline personality disorder is to establish clear boundaries. Individuals with this disorder struggle with impulsivity and have difficulty recognizing and respecting boundaries in their relationships. By establishing clear boundaries, it helps provide structure and consistency to the client, aiding in their treatment and management of the disorder. Exploring vocational possibilities may be important at some point, but it is not the priority intervention for managing borderline personality disorder. Discussing feelings of victimization, while common, may not be as effective initially due to the client's lack of insight and resistance. Spending 1 to 2 hours per day with the client may not be as productive as shorter, more focused interactions that are geared towards boundary reinforcement.

5. Which response would the nurse make at lunchtime to a client who is sitting alone with the head slightly tilted as if listening to something?

• A. "I know you're busy, but it's lunchtime."
• B. "Are the voices bothering you again?"
• C. "Get going; you don't want to miss lunchtime."
• D. "It's lunchtime; I'll walk with you to the dining room."

Correct answer: D

Rationale: The statement, "It's lunchtime; I'll walk with you to the dining room," demonstrates setting limits and providing support. Hallucinations can be frightening, and the nurse's presence offers support and reality without focusing on the hallucination directly. Choice A, "I know you're busy, but it's lunchtime," does not recognize the client's need for support and direction. Choice B, "Are the voices bothering you again?", makes a judgment without sufficient evidence and overly focuses on the hallucination, failing to address the client's need for support and direction. Choice C, "Get going; you don't want to miss lunchtime," does not acknowledge the client's need for reality, support, and direction, and may come across as threatening.

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