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 nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

• A. Pericardial friction rub
• B. Mitral stenosis
• C. Aortic regurgitation
• D. Tricuspid stenosis

Correct answer: B

Rationale: The correct answer is B: Mitral stenosis. A high-pitched scratching sound heard during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border indicates mitral stenosis, not a pericardial friction rub. Pericardial friction rub is a to-and-fro, grating, or scratching sound due to inflamed pericardial surfaces rubbing together, typically heard in early diastole and late systole. Aortic regurgitation and tricuspid stenosis would present with different auscultatory findings compared to the described scenario, making them incorrect choices in this context.

3. A healthcare professional is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the healthcare professional initiate?

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

Correct answer: B

Rationale: The correct answer is B: Droplet. Droplet precautions are required for infections that spread via droplets larger than 5 microns in diameter, such as pharyngeal diphtheria. Contact precautions are used for diseases that spread by direct or indirect contact. Airborne precautions are for diseases that spread through small particles in the air. Protective precautions are not a standard precautionary measure for specific infections like pharyngeal diphtheria.

4. A client is to receive cimetidine (Tagamet) 300 mg q6h IVP. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The LPN plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?

• A. 150
• B. 50
• C. 100
• D. 75

Correct answer: A

Rationale: Setting the infusion pump to 150 ml/hr ensures the correct administration rate of the IVPB dose over 20 minutes. To calculate the infusion rate, consider that the total volume to be infused is 50 ml over 20 minutes. To convert this to ml/hr, the calculation is (50 ml / 20 minutes) x 60 minutes/hr = 150 ml/hr. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate needed to deliver the secondary infusion over the specified time.

5. A client with a diagnosis of myocardial infarction (MI) is being treated. Which laboratory value would be most concerning?

• A. Troponin level of 0.5 ng/mL
• B. Creatine kinase-MB (CK-MB) of 5.0 ng/mL
• C. Serum potassium of 4.5 mEq/L
• D. Blood glucose of 180 mg/dL

Correct answer: A

Rationale: A troponin level of 0.5 ng/mL is elevated, indicating myocardial damage, making it the most concerning finding in a client with a myocardial infarction (MI). Troponin is a highly specific marker for cardiac muscle damage, and elevated levels suggest ongoing injury to the heart muscle. While Creatine kinase-MB (CK-MB) is also a cardiac enzyme, troponin is more specific and sensitive for myocardial damage. Serum potassium and blood glucose levels are important parameters to monitor in MI patients, but in this scenario, the elevated troponin level takes precedence as it directly reflects cardiac injury.

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