Nursing Elites

1. A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

• A. Oral mucosa
• B. Conjunctivae
• C. Soles of the feet
• D. Ear lobes

Correct answer: A

Rationale: Central cyanosis is best assessed by examining the oral mucosa, as it is a more reliable indicator compared to other areas like the conjunctivae, soles of the feet, and ear lobes. The oral mucosa reflects the oxygen saturation levels of the blood more accurately. Conjunctivae and ear lobes may show cyanosis, but they are not as reliable as the oral mucosa. The soles of the feet are not typically used to assess central cyanosis.

2. The nurse is observing the way a patient walks. What aspect is the nurse assessing?

• A. Body alignment
• B. Gait
• C. Activity tolerance
• D. Range of motion

Correct answer: B

Rationale: The correct answer is B: Gait. Gait refers to the manner in which a person walks, including aspects such as stride length, step width, and walking speed. When a nurse observes a patient's gait, they are assessing their mobility and looking for any abnormalities or issues in their walking pattern. Choice A, body alignment, focuses more on the posture and position of the body rather than the actual walking pattern. Choice C, activity tolerance, relates to the ability to withstand physical activity without experiencing excessive fatigue. Choice D, range of motion, pertains to the extent of movement at a joint and is not directly related to observing the way a patient walks.

3. Which factor places a patient at the highest risk for infection?

• A. A healthy immune system
• B. Presence of chronic illness
• C. Being well-nourished
• D. Age over 65 years

Correct answer: B

Rationale: The presence of chronic illness is the factor that places a patient at the highest risk for infection. Chronic illness can compromise the immune system's ability to fight off infections effectively, making individuals more susceptible to getting sick. Option A, a healthy immune system, actually reduces the risk of infection. Option C, being well-nourished, can support overall health but does not directly correlate with infection risk. While age over 65 years is a risk factor for certain infections due to age-related immune system changes, chronic illness has a more significant impact on infection risk.

4. A healthcare provider writes a prescription for a medication dose three times the normal range. What should the nurse do?

• A. Administer the medication as prescribed
• B. Question the prescription with the provider
• C. Consult with the pharmacist about the dosage
• D. Delay the medication until verification can be made

Correct answer: B

Rationale: The correct action for the nurse in this situation is to question the prescription with the provider. Administering a medication dose three times the normal range without clarification could pose serious risks to the client. Consulting with the pharmacist about the dosage or delaying the medication until verification can be made are not the initial steps to take; the nurse should first clarify the prescription with the healthcare provider to ensure patient safety.

5. A community nurse is instructing a group of newly licensed nurses about diseases that require airborne precautions. Which of the following diseases should the nurse include?

• A. Rubella
• B. Pertussis
• C. Influenza
• D. Varicella

Correct answer: D

Rationale: The correct answer is D, Varicella. Varicella (chickenpox) is a disease that requires airborne precautions to prevent its spread. Airborne precautions are necessary to prevent transmission of pathogens that remain infectious over long distances when suspended in the air. Rubella, pertussis, and influenza do not require airborne precautions. Rubella and pertussis require droplet precautions, while influenza requires droplet and contact precautions. Therefore, Varicella is the only disease in the list that necessitates airborne precautions.

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