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. A community hit by a hurricane has suffered mass destruction and flooding. Several facilities are not functioning, and the area is contaminated with human excretions. The nurse is developing a plan of care for clients diagnosed with cholera after an outbreak. Which intervention has the highest priority?

• A. Administer prophylactic antibiotics as prescribed.
• B. Provide fluid and electrolyte replacement.
• C. Isolate all infectious diarrhea victims.
• D. Administer cholera vaccine.

Correct answer: B

Rationale: Providing fluid and electrolyte replacement is the highest priority to prevent dehydration and shock in clients with cholera. Administering prophylactic antibiotics may be necessary but is not the highest priority. Isolating infectious diarrhea victims is important for preventing the spread of infection, but addressing fluid and electrolyte imbalances takes precedence. Administering a cholera vaccine is preventive and not the immediate priority in treating clients already diagnosed with cholera.

3. A 55-year-old client with symptoms of osteoarthritis asks which form of exercise would be most beneficial. What is the best response by the nurse?

• A. Walking.
• B. Running.
• C. Swimming.
• D. Weight lifting.

Correct answer: C

Rationale: The correct answer is C: 'Swimming.' Swimming is a low-impact exercise that helps maintain joint mobility and reduce pain in clients with osteoarthritis. Unlike running or weight lifting, swimming is gentle on the joints, making it an ideal choice for individuals with osteoarthritis. Walking can be beneficial too, but swimming is often preferred due to its low-impact nature. Running and weight lifting may exacerbate joint pain and should be avoided by individuals with osteoarthritis.

4. Which is a long-term complication of cleft lip and palate?

• A. Cognitive impairment
• B. Altered growth and development
• C. Faulty dentition
• D. Physical abilities

Correct answer: C

Rationale: The correct answer is C, 'Faulty dentition.' The older child with cleft lip and palate may experience psychological difficulties due to the cosmetic appearance of the defect, issues with impaired speech, and faulty dentition. This can lead to problems with dental alignment, crowding, missing or malformed teeth, and other dental issues. Choices A, B, and D are incorrect as cognitive impairment, altered growth and development, and physical abilities are not typically considered long-term complications of cleft lip and palate.

5. A young adult client, admitted to the emergency department following a motor vehicle collision, is transfused with 4 units of PRBCs. The client’s pretransfusion hematocrit is 17%. Which hematocrit value should the nurse expect the client to have after all PRBCs have been transfused?

• A. 23%
• B. 25%
• C. 27%
• D. 29%

Correct answer: D

Rationale: One unit of PRBCs typically raises the hematocrit by 3%. Since the client received 4 units, the hematocrit is expected to increase by approximately 12% (4 units x 3% per unit). Therefore, the nurse should expect the client's hematocrit to be 29% after all PRBCs have been transfused. Choices A, B, and C are incorrect as they do not account for the cumulative effect of multiple PRBC units on the hematocrit level.

Similar Questions