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 has a terminal diagnosis and their health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

• A. Offering to discuss advance directives and provide brochures respects the client's request and provides information.
• B. Informing the client that advance directives are not necessary at this time is incorrect as they play a crucial role in end-of-life care.
• C. Scheduling a meeting with the family to discuss advance directives is not the most appropriate response as the client directly requested information.
• D. Directing the client to ask their provider about advance directives does not directly address the client's request for information.

Correct answer: A

Rationale: When a client with a terminal illness asks about advance directives, it is essential to provide the information they seek. Choice A is the correct response as it acknowledges the client's request and offers to discuss advance directives while providing additional resources in the form of brochures. This approach empowers the client to make informed decisions about their end-of-life care. Choices B, C, and D are incorrect because they do not directly address the client's request or provide the information the client is seeking. Choice B dismisses the importance of advance directives, which are crucial in end-of-life care planning. Choice C involves the family unnecessarily when the client directly requested information. Choice D deflects the responsibility back to the client to seek information from their provider instead of addressing their immediate request.

3. While changing the linen on the client's bed, what should the nurse do?

• A. Hold the linen away from their body and clothing.
• B. Fold the linen neatly before placing it in the laundry.
• C. Wear clean gloves while handling the linen.
• D. Place the linen directly on the floor until the new linen is in place.

Correct answer: A

Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.

4. In a disaster at a child day care center, which child would the triage nurse prioritize for treatment last?

• A. An infant with intermittent bulging anterior fontanel between crying episodes
• B. A toddler with severe deep abrasions covering 98% of the body
• C. A preschooler with a lower leg fracture and an upper leg fracture on the other leg
• D. A school-age child with singed eyebrows and hair on the arms

Correct answer: B

Rationale: The toddler with severe deep abrasions covering 98% of the body would be prioritized for treatment last because these extensive injuries may require immediate attention and resources. The other choices present serious conditions but are not as severe or life-threatening as the toddler's injuries. The infant with an intermittent bulging anterior fontanel may have signs of increased intracranial pressure, requiring prompt evaluation. The preschooler's fractures, though serious, can be managed without immediate critical intervention. The school-age child with singed eyebrows and hair may have suffered burns but does not exhibit injuries as severe as the toddler's deep abrasions.

5. The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?

• A. Infuse normal saline at a keep-vein-open rate.
• B. Discontinue the IV and flush the port with heparin.
• C. Infuse 10% dextrose and water at 54 ml/hr.
• D. Obtain a stat blood glucose level and notify the healthcare provider.

Correct answer: C

Rationale: Infusing 10% dextrose and water at 54 ml/hr is the correct action to prevent hypoglycemia until the next TPN solution becomes available. This solution will help maintain the client's glucose levels. Infusing normal saline at a keep-vein-open rate (Choice A) is not appropriate for maintaining glucose levels and would not address the nutritional needs provided by TPN. Discontinuing the IV and flushing the port with heparin (Choice B) is unnecessary and not indicated in this situation as the client still needs fluid and nutrition. Obtaining a stat blood glucose level and notifying the healthcare provider (Choice D) can be done later but is not the immediate action required when the TPN solution has run out.

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