Nursing Elites

1. A client is hospitalized for an infection of a surgical wound following abdominal surgery. To promote healing and fight wound infection, the nurse plans to arrange to increase the client's intake of:

• A. Vitamin C and Zinc
• B. Vitamin B12 and Calcium
• C. Vitamin D and Iron
• D. Vitamin A and Potassium

Correct answer: A

Rationale: The correct answer is A: Vitamin C and Zinc. Vitamin C is essential for collagen synthesis, which is important for wound healing. Zinc plays a crucial role in immune function and also aids in wound healing. Vitamin B12 and Calcium (Choice B) are not directly associated with wound healing properties. Vitamin D and Iron (Choice C) are important for overall health but are not specifically targeted for wound healing. Vitamin A and Potassium (Choice D) do not have direct wound healing properties and are not the best choices to promote wound healing and fight infection.

2. A nurse is caring for a group of clients. How should the nurse prevent the spread of infection?

• A. Place a client with TB in a negative pressure room.
• B. Use standard precautions only.
• C. Place a client with TB in a private room.
• D. Use barrier precautions only.

Correct answer: A

Rationale: The correct answer is to place a client with TB in a negative pressure room. Tuberculosis (TB) is an airborne infectious disease, and placing the client in a negative pressure room helps prevent the spread of the infection by containing and filtering the air within the room. Standard precautions (Choice B) are important for preventing the spread of infection in general, but specific precautions are needed for airborne diseases like TB. Placing the client in a private room (Choice C) may not provide adequate ventilation and containment of airborne pathogens. Using barrier precautions (Choice D) alone is not sufficient for preventing the airborne transmission of TB.

3. 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.

4. In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will:

• A. Be at an increased susceptibility for infection
• B. Have a wound that heals more slowly
• C. Experience more pain during the healing process
• D. Require more frequent dressing changes

Correct answer: A

Rationale: Wounds healing by secondary intention involve the gradual filling of the wound with granulation tissue, leading to a higher risk of infection due to prolonged exposure. This makes choice A the correct answer. Choices B and C are incorrect because wounds healing by secondary intention take longer to heal and often result in more pain compared to wounds healing by primary intention. Choice D is also incorrect as wounds healing by secondary intention usually require more frequent dressing changes to prevent infection and promote healing.

5. A client requires gastric decompression, and a nurse is inserting an NG tube. Which action should the nurse take to verify proper placement of the tube?

• A. Assess the client for a gag reflex
• B. Measure the pH of the gastric aspirate
• C. Place the end of the NG tube in water to observe for bubbling
• D. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water

Correct answer: B

Rationale: Measuring the pH of the gastric aspirate is the most reliable method to confirm proper placement of an NG tube. Gastric fluid has an acidic pH, typically ranging from 1 to 5. Assessing the client for a gag reflex (choice A) is important for airway protection but does not confirm tube placement. Placing the NG tube in water to observe for bubbling (choice C) is incorrect and not a reliable method for verifying placement. Auscultating 2.5 cm above the umbilicus while injecting sterile water (choice D) is an outdated method and is not recommended for verifying NG tube placement.

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