Nursing Elites

1. The client with partial-thickness (second-degree) and full-thickness (third-degree) burns is at risk of infection. What intervention has the highest priority in decreasing the client's risk of infection?

• A. Administration of plasma expanders
• B. Use of careful handwashing technique
• C. Application of a topical antibacterial cream
• D. Limiting visitors to the client with burns

Correct answer: B

Rationale: The correct answer is the use of careful handwashing technique. Proper handwashing is the most effective way to prevent the transmission of infectious organisms. Option A, administration of plasma expanders, addresses hypovolemia in burn patients but does not directly decrease the risk of infection. Option C, application of a topical antibacterial cream, is beneficial but not as effective as proper handwashing in preventing infection. Option D, limiting visitors, may help reduce the risk of exposure to pathogens but is not as critical as ensuring healthcare providers maintain strict hand hygiene, which is the cornerstone of infection control in any healthcare setting.

2. While communicating with a client, the nurse determines that the client has realized the harmful effects of alcohol consumption and plans to stop drinking within 6 months. Which stage of the transtheoretical model of change would the nurse correlate the client's behavior with?

• A. Action
• B. Preparation
• C. Maintenance
• D. Contemplation

Correct answer: D

Rationale: The transtheoretical model of change defines changing patterns in individuals across five stages based on their readiness to change. The stages are precontemplation, contemplation, preparation, action, and maintenance. In the contemplation stage, the client acknowledges the benefits of change and considers making the change within the next 6 months. This aligns with the client's realization of the harmful effects of alcohol consumption and intent to stop drinking within 6 months. The action stage involves actively making changes, the preparation stage includes goal-setting with an intention to change within 60 days, and the maintenance stage focuses on sustaining changed behavior for at least 6 months and taking preventive measures to avoid relapse. Therefore, in this scenario, the client's behavior aligns with the contemplation stage of the transtheoretical model of change.

3. What is the nurse's initial plan for providing pain relief measures during labor for a pregnant client with a history of opioid abuse?

• A. Scheduling pain medication at regular intervals
• B. Administering the medication only when the pain is severe
• C. Avoiding the administration of medication unless it is requested
• D. Recognizing that less pain medication will be needed by this client compared with other women in labor

Correct answer: A

Rationale: In a pregnant client with a history of opioid abuse, scheduling pain medication at regular intervals is the initial plan for providing pain relief during labor. This client may have a lower tolerance for pain and a greater need for pain relief. If medication is only administered when the pain is severe, larger doses may be needed, leading to increased anxiety and discomfort. Avoiding medication unless requested is not ideal, as proactive pain management is crucial during labor. Recognizing that less pain medication will be needed by this client compared with others is incorrect, as individuals with a history of opioid abuse often require more medication due to tolerance to addictive drugs.

4. Which behavior indicates that the client has learned the most effective method to cope with anger?

• A. Goes for a long jog
• B. Talks about the anger
• C. Goes outside and screams
• D. Focuses on cause of anger

Correct answer: B

Rationale: The correct answer is 'Talks about the anger.' This response indicates that the client has learned a positive coping method, as discussing angry feelings is a healthier way of dealing with anger. Talking about anger allows for expression and communication, leading to a better understanding of the emotions involved. Going for a long jog or screaming outside may provide temporary relief, but they do not address the root cause or help in processing the emotions effectively. Focusing solely on the cause of anger without expressing feelings may lead to increased frustration and escalation of anger, rather than promoting constructive coping mechanisms.

5. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?

• A. Provide the client with a list of reliable internet sites that offer information on medications.
• B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
• C. Reassure the client that information about the medication is included in the written instructions.
• D. Encourage the client to call the clinic nurse or healthcare provider if any questions arise.

Correct answer: D

Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or healthcare provider if any questions arise. This direct communication allows for personalized assistance and clarification tailored to the client's specific concerns. Providing Internet sites (Choice A) may lead to unreliable information, and a drug reference book (Choice B) may not address individualized questions. While the written instructions may contain information (Choice C), they may not cover all potential queries the client might have, making direct contact with the healthcare provider the most appropriate option.

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