Nursing Elites

1. A nurse in an emergency department is caring for a client who reports cocaine use 1 hour ago. Which of the following findings should the nurse expect?

• A. Hypotension.
• B. Memory loss.
• C. Slurred speech.
• D. Elevated temperature.

Correct answer: D

Rationale: The correct answer is D: Elevated temperature. Cocaine is a stimulant drug that can lead to increased body temperature. Hypotension (Choice A) is less likely as cocaine tends to elevate blood pressure. Memory loss (Choice B) and slurred speech (Choice C) are more commonly associated with depressant drugs rather than stimulant drugs like cocaine.

2. A nurse is caring for a client who has a Clostridium difficile infection. Which of the following precautions should the nurse implement?

• A. Place the client in a negative pressure room
• B. Wear an N95 respirator mask when entering the room
• C. Wear a gown and gloves when providing care to the client
• D. Place a face mask on the client

Correct answer: C

Rationale: The correct precaution to implement when caring for a client with Clostridium difficile infection is to wear a gown and gloves when providing care. Clostridium difficile is primarily spread through contact with feces, so wearing personal protective equipment like gowns and gloves is crucial in preventing the spread of the infection. Placing the client in a negative pressure room (Choice A) is not necessary for Clostridium difficile. While wearing an N95 respirator mask (Choice B) is important for airborne precautions, it is not required for Clostridium difficile. Placing a face mask on the client (Choice D) is not a standard precaution for preventing the spread of Clostridium difficile.

3. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

• A. Place the cap from the solution sterile side up on a clean surface.
• B. Open the outermost flap of the sterile kit away from the body.
• C. Place the sterile dressing within 1.25 cm of the edge of the sterile field.
• D. Set up the sterile field 5 cm below waist level.

Correct answer: B

Rationale: When setting up a sterile field for a dressing change, the nurse should open the outermost flap of the sterile kit away from the body. This action helps maintain the sterility of the field by minimizing the risk of contamination. Option A is incorrect because the cap from the solution should be placed sterile side down to prevent contamination. Option C is incorrect because the sterile dressing should be placed at least 1.25 cm away from the edge of the sterile field to maintain its sterility. Option D is incorrect because the sterile field should be set up above waist level to prevent potential contamination from reaching the field.

4. What is the best way to assess for fluid overload in a patient with heart failure?

• A. Check daily weight
• B. Check blood pressure
• C. Monitor heart sounds
• D. Assess for jugular vein distention

Correct answer: A

Rationale: The correct answer is to 'Check daily weight.' Monitoring daily weight is the most accurate method to assess for fluid overload in patients with heart failure. Weight gain can indicate fluid retention, a common issue in heart failure patients. Checking blood pressure (Choice B) can provide information about hemodynamic status but may not be as specific for fluid overload as monitoring weight. Monitoring heart sounds (Choice C) can provide information about cardiac function but may not directly assess fluid overload. Assessing for jugular vein distention (Choice D) can be a sign of increased central venous pressure but may not always correlate with fluid overload as accurately as daily weight checks.

5. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Stay in bed for at least 1 hour if unable to fall asleep.
• B. Take a 1-hour nap during the day.
• C. Perform exercise before bed.
• D. Eat a light snack before bedtime.

Correct answer: D

Rationale: The correct answer is to eat a light snack before bedtime. Consuming a light snack can help promote sleep by preventing discomfort from hunger. Choice A is incorrect because staying in bed for too long when unable to fall asleep can lead to frustration and worsen insomnia. Choice B is incorrect as taking a nap during the day can interfere with nighttime sleep. Choice C is incorrect as exercising before bed can increase alertness and make falling asleep more difficult.

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