Nursing Elites

1. A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5mm of erythema without induration. Which is the best initial nursing action?

• A. Review the healthcare worker's history for possible exposure to TB.
• B. Instruct the healthcare worker to return for a repeat test in 1 week.
• C. Refer the healthcare worker to a healthcare provider for isoniazid (INH) therapy.
• D. Document negative results in the healthcare worker's medical record.

Correct answer: D

Rationale: A Mantoux tuberculosis skin test without induration is considered negative. In this case, with 5mm of erythema and no induration, the result is negative, indicating no current infection. The best initial nursing action is to document these negative results in the healthcare worker's medical record. Reviewing the history for possible exposure to TB is unnecessary as the test result is negative. Instructing the healthcare worker to return for a repeat test or referring for INH therapy is not warranted when the test is negative.

2. In the change of shift report, the nurse is told that a client has a stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?

• A. Shallow open ulcer with a red-pink wound bed.
• B. Intact skin with non-blanchable redness.
• C. Full-thickness tissue loss with visible fat.
• D. Full-thickness tissue loss with exposed bone, tendon, or muscle.

Correct answer: A

Rationale: The correct answer is A: 'Shallow open ulcer with a red-pink wound bed.' Stage 2 pressure ulcers involve partial-thickness skin loss and typically appear as shallow open ulcers with a red-pink wound bed. Choice B describes a stage 1 ulcer, where the skin is intact but shows non-blanchable redness. Choice C describes a stage 3 ulcer, with full-thickness tissue loss exposing fat. Choice D is characteristic of a stage 4 ulcer, where there is full-thickness tissue loss exposing bone, tendon, or muscle. Therefore, option A best fits the description of a stage 2 pressure ulcer.

3. The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum?

• A. Breathe deeply, followed by swallowing.
• B. Breathe deeply, followed by spitting into a cup.
• C. Breathe deeply, followed by coughing up the sputum.
• D. Breathe deeply, followed by clearing the throat.

Correct answer: C

Rationale: The correct answer is to instruct the client to breathe deeply followed by coughing up the sputum. This method ensures that the specimen is collected from the lower respiratory tract and is not contaminated by saliva. Choice A (swallowing) does not result in sputum collection, while choice B (spitting into a cup) may lead to saliva contamination. Choice D (clearing the throat) is not an effective way to collect sputum as it may involve getting rid of saliva, not sputum.

4. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?

• A. Daily weight
• B. Vital signs
• C. Level of consciousness
• D. Bowel sounds

Correct answer: A

Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.

5. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

• A. Nuchal rigidity
• B. Carotid bruit
• C. Jugular vein distention
• D. Palpable cervical lymph node

Correct answer: B

Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.

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