Nursing Elites

1. A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching?

• A. I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial.
• B. MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed.
• C. I will protect others from exposure when I transport the client outside the room.
• D. To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile.

Correct answer: C

Rationale: The correct answer is C. Protecting others from exposure when transporting a client with MRSA is crucial in preventing the spread of infection. This statement demonstrates understanding of infection control measures. Stating that MRSA is usually resistant to vancomycin (choice B) is incorrect; vancomycin is often effective against MRSA. Obtaining a specimen for culture and sensitivity after the first dose of an antimicrobial (choice A) is unnecessary and not indicated. Discontinuing antimicrobial therapy when the client is no longer febrile (choice D) is incorrect because antimicrobial therapy should be completed as prescribed to prevent the development of resistant strains.

2. A client with a history of severe anxiety is scheduled for surgery. Which preoperative medication is the most appropriate for the LPN/LVN to administer to this client?

• A. Lorazepam (Ativan)
• B. Morphine sulfate
• C. Meperidine (Demerol)
• D. Promethazine (Phenergan)

Correct answer: A

Rationale: Lorazepam (Ativan) is the most appropriate preoperative medication for a client with severe anxiety. Lorazepam belongs to the benzodiazepine class and is commonly used to manage anxiety before surgical procedures due to its anxiolytic properties. Morphine sulfate and Meperidine (Demerol) are opioid analgesics, not typically indicated for preoperative anxiety. Promethazine (Phenergan) is an antihistamine used for nausea and vomiting, not anxiety management.

3. During assessment, what is an indication of thrombophlebitis in a client who has been on bed rest for the past month?

• A. Calf swelling
• B. Elevated blood pressure
• C. Decreased urine output
• D. Generalized rash

Correct answer: A

Rationale: Calf swelling is a common sign of thrombophlebitis, which is inflammation of a vein due to a blood clot. Prolonged immobility can predispose individuals to thrombophlebitis. Calf swelling occurs due to the obstruction of blood flow, causing localized edema. This condition can lead to serious complications like pulmonary embolism if not promptly addressed. Elevated blood pressure, decreased urine output, and a generalized rash are not typically associated with thrombophlebitis. Elevated blood pressure may be linked to other conditions like hypertension, decreased urine output to kidney dysfunction, and a generalized rash to allergic reactions or skin conditions. Therefore, in a client on bed rest, calf swelling should raise suspicion of thrombophlebitis and prompt further evaluation and intervention.

4. During a skin assessment, a client expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy?

• A. A mole with an asymmetrical appearance.
• B. A mole with a regular border.
• C. A mole that is the same color throughout.
• D. A mole that is smaller than 6mm in diameter.

Correct answer: A

Rationale: The correct answer is A: A mole with an asymmetrical appearance. Asymmetry is a key characteristic of potential skin malignancy. An asymmetrical mole does not have a uniform shape when divided in half. This irregularity raises suspicion for skin cancer. Choices B, C, and D are incorrect. A mole with a regular border (B) is more likely to be benign. A mole that is the same color throughout (C) is also a feature commonly seen in benign moles. Additionally, a mole smaller than 6mm in diameter (D) is not necessarily indicative of malignancy, as some melanomas can be smaller or larger than this size.

5. The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next?

• A. Stand to the side of the patient's eye and observe the cornea.
• B. Conclude that the glasses were lost during the accident.
• C. Notify the ambulance personnel about the missing glasses.
• D. Ask the patient where the glasses are.

Correct answer: A

Rationale: In this scenario, the nurse should stand to the side of the patient's eye and observe the cornea. This action is crucial in assessing whether the patient wears contact lenses, especially in unresponsive patients. Observing the cornea can provide valuable information about the patient's eye health and potential use of contact lenses. Choices B, C, and D are incorrect. Concluding that the glasses were lost during the accident is premature without proper assessment. Notifying ambulance personnel about the missing glasses may not be the immediate priority, and asking the unresponsive patient about the glasses would not yield useful information in this situation.

Similar Questions