Nursing Elites

1. A nurse is assisting with a presentation at a community center about personal disaster preparedness. Which of the following strategies should the nurse recommend for preparing a home disaster supply kit?

• A. Store enough water for 3 days
• B. Maintain communication with family
• C. Prepare only non-perishable food
• D. Prepare multiple escape routes

Correct answer: A

Rationale: The correct answer is A: 'Store enough water for 3 days.' When preparing a home disaster supply kit, it is crucial to include enough water to last at least 3 days. This is because clean drinking water may not be readily available during a disaster situation. Choice B, 'Maintain communication with family,' is important for coordination but not directly related to preparing a supply kit. Choice C, 'Prepare only non-perishable food,' is also important but does not address the specific recommendation for water. Choice D, 'Prepare multiple escape routes,' is crucial for evacuation planning but does not pertain to the contents of a home disaster supply kit.

2. A nurse is planning to irrigate and dress a clean, granulating wound for a client. Which of the following actions should the nurse take?

• A. Irrigate the wound with normal saline.
• B. Apply a wet-to-dry gauze dressing.
• C. Use a cotton ball to cleanse the wound.
• D. Administer an analgesic after the dressing change.

Correct answer: A

Rationale: The correct answer is to irrigate the wound with normal saline. Normal saline is the preferred solution for wound irrigation as it is isotonic and gentle, promoting healing in granulating wounds. Choice B, applying a wet-to-dry gauze dressing, is not appropriate for clean, granulating wounds as it can cause trauma to the wound bed upon removal. Choice C, using a cotton ball to cleanse the wound, is not ideal as cotton fibers can adhere to the wound and cause contamination. Choice D, administering an analgesic after the dressing change, is important for pain management but is not directly related to irrigating and dressing the wound.

3. What are the potential complications of a patient receiving total parenteral nutrition (TPN)?

• A. Infection and electrolyte imbalance
• B. Hyperglycemia and sepsis
• C. Kidney failure and hypovolemia
• D. Fluid overload and liver damage

Correct answer: A

Rationale: Infection and electrolyte imbalance are common complications of TPN. Infection can occur due to the invasive nature of TPN, which provides a direct route for pathogens. Electrolyte imbalances can arise from the composition of the TPN solution or improper monitoring. Hyperglycemia and sepsis (Choice B) are potential complications but are not as directly associated with TPN as infection and electrolyte imbalance. Kidney failure and hypovolemia (Choice C) are less common complications of TPN. Fluid overload and liver damage (Choice D) are potential complications but are not as frequently observed as infection and electrolyte imbalance.

4. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?

• A. Explain the experience of having delirium
• B. Resume a normal sleep-wake cycle
• C. Regain orientation to time and place
• D. Establish normal bowel and bladder function

Correct answer: C

Rationale: Regaining orientation to time and place is a realistic short-term goal for clients with delirium. It helps the individual become aware of their surroundings and current situation, aiding in reducing confusion and disorientation. Choice A is incorrect because the goal is focused on the client's understanding, not on explaining the experience of delirium. Choice B, resuming a normal sleep-wake cycle, may take longer than 2 to 3 days to achieve and is not directly related to regaining orientation. Choice D, establishing normal bowel and bladder function, is important but may not be a short-term goal specifically related to delirium.

5. A client who is at 38 weeks of gestation and has a history of hepatitis C asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?

• A. You may breastfeed unless your nipples are cracked or bleeding.
• B. You must use a breast pump to provide breast milk.
• C. You must use a nipple shield when breastfeeding.
• D. You may breastfeed after your baby develops antibodies.

Correct answer: A

Rationale: The correct response is A: 'You may breastfeed unless your nipples are cracked or bleeding.' In the case of hepatitis C, breastfeeding is generally safe unless the mother's nipples are cracked or bleeding, which could increase the risk of transmission to the baby. Choice B is incorrect as using a breast pump is not a mandatory requirement for breastfeeding with hepatitis C. Choice C is incorrect as a nipple shield is not necessary in this situation. Choice D is incorrect because the baby developing antibodies does not impact the decision to breastfeed in the context of hepatitis C.

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