Nursing Elites

1. When providing postmortem care to a client diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) who has passed away, what type of precautions is appropriate to use?

• A. Airborne precautions
• B. Droplet precautions
• C. Contact precautions
• D. Compromised host precautions

Correct answer: C

Rationale: Contact precautions are the appropriate type to use when performing postmortem care for a client with MRSA. MRSA is primarily spread through direct contact, so using contact precautions helps prevent the transmission of the infection. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air like tuberculosis or measles. Droplet precautions are used for diseases transmitted through respiratory droplets like influenza. Compromised host precautions are not a standard precaution type and are not specific to managing MRSA infection.

2. A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?

• A. Choose the most distal site on the selected extremity
• B. Apply a cool compress to the selected extremity before insertion of the IV catheter
• C. Stroke the selected extremity before insertion of the IV catheter
• D. Place the tourniquet above the proposed insertion site

Correct answer: C

Rationale: When preparing to insert an IV catheter, stroking the extremity before insertion helps to visualize veins, making it easier to locate a suitable vein for catheter insertion. Choosing the most distal site on the extremity is correct because veins more distal are preferred for IV catheter insertion. Applying a cool compress to the extremity before insertion is unnecessary and not a standard practice. Placing the tourniquet below the proposed insertion site is incorrect; the tourniquet should be placed above the proposed insertion site to help engorge the veins for easier visualization and access.

3. When providing a bath, in which order will the nurse clean the body, beginning with the first area?

• A. Face
• B. Eyes
• C. Perineum
• D. Back and buttocks

Correct answer: B

Rationale: The correct sequence for giving a bath starts with cleaning the eyes, followed by the face, both arms, chest, hands/nails, abdomen, both legs, perineal hygiene, back, and finally the buttocks/anus. Therefore, the first area to be cleaned during a bath is the eyes. Choices A, C, and D are incorrect as per the standard procedure for providing a bath.

4. A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client’s abdomen, the nurse expects the bowel sounds to be:

• A. Absent
• B. Hyperactive
• C. Normal
• D. Hypoactive

Correct answer: A

Rationale: In paralytic ileus, bowel sounds are typically absent or significantly reduced due to decreased motility of the intestines. This absence of bowel sounds is a key characteristic used in diagnosing paralytic ileus. Hyperactive bowel sounds are not expected in this condition as there is a lack of normal peristalsis. Normal bowel sounds would not be present in paralytic ileus, and hypoactive bowel sounds, which indicate decreased bowel motility, are more commonly associated with conditions like postoperative ileus or constipation, rather than paralytic ileus.

5. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?

• A. Wear cotton clothing to avoid static electricity.
• B. Avoid using any electrical appliances.
• C. Keep the oxygen tank away from heat sources.
• D. Use only a specific type of nasal cannula.

Correct answer: A

Rationale: The correct answer is A: Wear cotton clothing to avoid static electricity. When using oxygen therapy, static electricity can pose a hazard as it increases the risk of fire. Cotton clothing helps reduce static electricity buildup. Choice B, avoiding electrical appliances, is overly restrictive and not entirely necessary. Choice C, keeping the oxygen tank away from heat sources, is important to prevent fire hazards but is not directly related to the nasal cannula. Choice D, using only a specific type of nasal cannula, is not a universal guideline and limits flexibility in care.

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