Nursing Elites

1. A client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

• A. Droplet
• B. Contact
• C. Airborne
• D. Protective

Correct answer: A

Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.

2. A client with prostate cancer declines to discuss concerns after the provider discusses treatment options. What statement should the nurse make?

• A. I am available to talk if you should change your mind.
• B. It’s important to discuss your concerns with the provider.
• C. You need to make a decision about your treatment options.
• D. Your concerns will be addressed at a later time.

Correct answer: A

Rationale: Offering to talk later if the client changes their mind respects their current choice and keeps the dialogue open. Choice B is not the best response as it may pressure the client to share concerns. Choice C is incorrect as it imposes a decision on the client. Choice D does not acknowledge the client's feelings in the moment and postpones addressing concerns.

3. The nurse is assessing a client who has just been admitted with a diagnosis of acute pancreatitis. Which finding is most important for the LPN/LVN to report to the healthcare provider immediately?

• A. Elevated serum lipase level
• B. Severe abdominal pain
• C. Nausea and vomiting
• D. Hypotension

Correct answer: D

Rationale: Hypotension is a critical finding that should be reported immediately in a client with acute pancreatitis as it may indicate severe complications such as hemorrhage or shock. While elevated serum lipase level, severe abdominal pain, and nausea/vomiting are common manifestations of acute pancreatitis, hypotension is a more urgent sign requiring immediate attention to prevent further deterioration. Hypotension can be a sign of significant fluid loss, hemorrhage, or sepsis, which are potentially life-threatening conditions that need prompt intervention. Elevated serum lipase levels, severe abdominal pain, and nausea/vomiting are important in the assessment of pancreatitis but do not indicate the same level of immediate danger as hypotension does.

4. UAP has lowered the head of the bed to change the linens for a client who is bedridden. Which observation...most immediate intervention by the nurse?

• A. A feeding is infusing at 40 mL/hr through an enteral feeding tube.
• B. The urine meter attached to the urinary drainage bag is completely full.
• C. There is a large dependent loop in the client's urinary drainage tubing.
• D. Purulent drainage is present around the insertion site of the feeding tube.

Correct answer: D

Rationale: The correct answer is D. Purulent drainage around the insertion site of the feeding tube indicates an infection, which requires immediate attention. This may be a sign of a serious complication that needs prompt nursing intervention to prevent further complications or deterioration in the client's condition. Choices A, B, and C do not indicate an immediate threat to the client's health. While option A highlights the infusion rate of the feeding, it does not pose an immediate risk compared to the presence of purulent drainage indicating infection.

5. What intervention can help prevent atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?

• A. Active and passive range of motion exercises twice a day
• B. Every 4 hours incentive spirometer
• C. Chest physiotherapy twice a day
• D. Repositioning every 2 hours around the clock

Correct answer: C

Rationale: Chest physiotherapy is essential for clients with amyotrophic lateral sclerosis (ALS) to prevent atelectasis and pneumonia. Chest physiotherapy aids in clearing secretions, maintaining lung function, and preventing respiratory complications. Active and passive range of motion exercises (Choice A) are important for maintaining joint mobility but are not directly associated with preventing atelectasis and pneumonia in ALS. Incentive spirometer use every 4 hours (Choice B) is beneficial for lung expansion and preventing atelectasis but may not be as effective as chest physiotherapy in managing secretions. Repositioning every 2 hours (Choice D) is crucial for preventing pressure ulcers but is not directly related to preventing atelectasis and pneumonia in ALS.

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