Nursing Elites

1. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?

• A. Screening groups of older adults in nursing care facilities for early influenza manifestations
• B. Promoting hand hygiene to prevent the spread of influenza
• C. Administering influenza vaccinations
• D. Educating about the importance of healthy lifestyle choices to prevent influenza

Correct answer: A

Rationale: The correct answer is A. Secondary prevention aims to detect and address health issues early. Screening older adults in nursing care facilities for early influenza manifestations is an example of secondary prevention by identifying cases at an early stage. Choice B, promoting hand hygiene, is a form of primary prevention that aims to prevent the occurrence of influenza. Choice C, administering influenza vaccinations, is a form of primary prevention as well, focusing on preventing the disease before it occurs. Choice D, educating about healthy lifestyle choices, is more related to health promotion and primary prevention rather than secondary prevention.

2. 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.

3. The healthcare provider is caring for a client with tuberculosis (TB). Which type of isolation precautions should the healthcare provider implement?

• A. Droplet precautions
• B. Airborne precautions
• C. Contact precautions
• D. Standard precautions

Correct answer: B

Rationale: When caring for a client with tuberculosis (TB), airborne precautions should be implemented. Tuberculosis is spread through the air via droplet nuclei, requiring the use of airborne precautions to prevent the transmission of the infection. Droplet precautions are used for diseases spread by large respiratory droplets, such as influenza or pertussis. Contact precautions are used for diseases that spread through direct contact, such as MRSA. Standard precautions are used for all clients to prevent the transmission of infections from blood, body fluids, non-intact skin, and mucous membranes.

4. The nurse is providing discharge teaching to a client who has a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

• A. I will take my pulse before taking the medication.
• B. I will take the medication at the same time every day.
• C. I should avoid taking antacids at the same time as this medication.
• D. I should eat foods high in potassium while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Clients taking digoxin should avoid eating foods high in potassium, as this can affect the medication's efficacy. Choices A, B, and C are correct statements regarding digoxin administration and precautions, indicating the client's understanding of the medication and its management.

5. The client is post-operative following abdominal surgery. Which of the following assessment findings would require immediate intervention?

• A. Absent bowel sounds
• B. Saturated abdominal dressing
• C. Pain level of 8/10
• D. Temperature of 100.4°F

Correct answer: B

Rationale: A saturated abdominal dressing is a critical finding that may indicate active bleeding or wound complications. Immediate intervention is necessary to prevent further complications, such as hypovolemic shock or infection. Absent bowel sounds, though abnormal, are a common post-operative finding and do not require immediate intervention. Pain level of 8/10 can be managed effectively with appropriate pain control measures and does not indicate an urgent issue. A temperature of 100.4°F is slightly elevated but may be a normal post-operative response to surgery and does not typically require immediate intervention unless accompanied by other concerning signs or symptoms.

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