Nursing Elites

1. A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)

• A. Send wound drainage for culture and sensitivity.
• B. Institute contact precautions for staff and visitors.
• C. Use standard precautions and wear a mask.
• D. Monitor the client's white blood cell count.

Correct answer: B

Rationale: When dealing with a client suspected of having MRSA, the nurse should implement contact precautions to prevent the spread of infection. This includes using gowns and gloves, along with following proper hand hygiene practices. Sending wound drainage for culture and sensitivity may be necessary for diagnostic purposes, but it is not directly related to preventing the spread of infection in this case. Using standard precautions and wearing a mask are not sufficient when dealing with MRSA; contact precautions are specifically required to prevent transmission. Monitoring the client's white blood cell count is important in assessing infection status but is not a primary intervention to prevent the spread of MRSA.

2. After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings indicating that the CVC tip is in the client's superior vena cava. Which action should the nurse implement?

• A. Remove the catheter and apply direct pressure for 5 minutes.
• B. Initiate intravenous fluids as prescribed.
• C. Secure the catheter using aseptic technique.
• D. Notify the healthcare provider of the need to reposition the catheter.

Correct answer: B

Rationale: Initiating intravenous fluids as prescribed is the appropriate action when the CVC tip is correctly placed in the superior vena cava. Intravenous fluids can now be administered effectively through the central line. Removing the catheter and applying direct pressure is unnecessary and not indicated as the tip is in the correct position. Securing the catheter using aseptic technique is important for preventing infections but is not the immediate action needed in this situation. Notifying the healthcare provider of the need to reposition the catheter may delay necessary fluid administration, which is the priority at this time.

3. The nurse is caring for a client with a chest tube after thoracic surgery. What is the most important assessment related to the chest tube?

• A. Ensure continuous bubbling in the water seal chamber
• B. Measure the amount of drainage every shift
• C. Keep the drainage system at the level of the chest
• D. Assess for subcutaneous emphysema around the insertion site

Correct answer: D

Rationale: The most important assessment related to a chest tube after thoracic surgery is to assess for subcutaneous emphysema around the insertion site. Subcutaneous emphysema can indicate air leakage from the pleural space, which can lead to serious complications such as a pneumothorax. Ensuring continuous bubbling in the water seal chamber is not the most critical assessment as it is a normal finding in a chest drainage system. While measuring the amount of drainage is important to monitor the client's condition, it is not as crucial as assessing for subcutaneous emphysema. Keeping the drainage system at the level of the chest helps maintain proper function but is not the most critical assessment in this scenario.

4. Which client assessment falls within the scope of practice for the practical nurse?

• A. An agitated client with bilateral wrist restraints
• B. New admission of a client with deep vein thrombosis
• C. Return of a post-anesthesia client following a colon resection
• D. Transfer of a client with sepsis from a long-term care facility

Correct answer: B

Rationale: The correct answer is B because assessing a new deep vein thrombosis (DVT) patient is within the scope of practical nursing. It involves monitoring and supporting the circulatory system health, which is a common responsibility for practical nurses. Choices A, C, and D involve scenarios that are typically beyond the initial assessment and care provided by practical nurses. An agitated client with bilateral wrist restraints may require immediate intervention by higher-level healthcare providers due to safety concerns and potential underlying issues. The return of a post-anesthesia client following a colon resection and the transfer of a client with sepsis involve more specialized care that goes beyond the typical responsibilities of a practical nurse, often requiring interventions from registered nurses or physicians.

5. A client with type 1 diabetes mellitus is learning to administer insulin. What is the best site for the nurse to recommend for insulin injection?

• A. Abdomen
• B. Thigh
• C. Upper arm
• D. Buttock

Correct answer: A

Rationale: The correct answer is the abdomen. The abdomen is the recommended site for insulin injection due to its faster absorption rate compared to other sites. Insulin injected into the abdomen is absorbed more quickly, leading to better glycemic control. The thigh and upper arm are also common sites for insulin injection, but they have slower absorption rates than the abdomen. The buttock is not a preferred site for insulin injection due to inconsistent absorption and potential risk of injecting into muscle instead of fatty tissue.

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