Nursing Elites

1. A client has C-diff infection. Which of the following actions should the nurse take?

• A. Give the client chlorhexidine gluconate for hand hygiene.
• B. Remove the protective gown first when exiting the client's room.
• C. Use alcohol-based hand rub when caring for the client.
• D. Initiate contact precautions when providing client care.

Correct answer: D

Rationale: The correct answer is to initiate contact precautions when providing client care. C-diff (Clostridium difficile) is highly contagious, and contact precautions are necessary to prevent its spread. Giving the client chlorhexidine gluconate for hand hygiene (Choice A) is not specific to managing C-diff. Removing the protective gown first when exiting the client's room (Choice B) may increase the risk of contaminating oneself and the environment. Using alcohol-based hand rub when caring for the client (Choice C) is not sufficient to prevent the transmission of C-diff, as soap and water are more effective against this particular pathogen.

2. During an abdominal assessment for an adult client, what is the correct sequence of steps?

• A. Inspect, Auscultate, Percuss, Palpate
• B. Palpate, Percuss, Inspect, Auscultate
• C. Auscultate, Inspect, Percuss, Palpate
• D. Percuss, Palpate, Inspect, Auscultate

Correct answer: A

Rationale: The correct sequence for an abdominal assessment in an adult client is to first Inspect the abdomen for any visible abnormalities, then Auscultate to listen for bowel sounds, followed by Percussion to assess for organ size and presence of fluid or masses, and finally Palpation to feel for tenderness, masses, or organ enlargement. Choice A, 'Inspect, Auscultate, Percuss, Palpate,' is the correct sequence for an abdominal assessment. Choices B, C, and D are incorrect because they do not follow the recommended sequence of assessment. Palpation should be the last step as it can potentially alter bowel sounds and percussion findings if done before. This deviation can lead to missing important findings or inaccurate assessment results.

3. When lifting a bedside cabinet to move it closer to a client who is sitting in a chair, which of the following actions should the nurse take to prevent self-injury?

• A. Bend at the waist
• B. Keep feet close together
• C. Use back muscles for lifting
• D. Stand close to the cabinet when lifting it

Correct answer: D

Rationale: The correct answer is to stand close to the cabinet when lifting it. This action keeps the object close to the nurse's center of gravity, reducing the risk of back strain. Bending at the waist (Choice A) can increase the risk of back injury as it puts strain on the lower back. Keeping feet close together (Choice B) does not provide a stable base of support for lifting a heavy object. Using back muscles for lifting (Choice C) is incorrect as it can lead to back strain and injury. Therefore, standing close to the cabinet when lifting it is the safest and most effective approach to prevent self-injury.

4. When transferring a postoperative client from the PACU following abdominal surgery, what action should the nurse take to move the client from the stretcher to the bed?

• A. Lock the wheels on both the bed and stretcher
• B. Adjust the bed to a low position
• C. Ask the client to assist in the transfer
• D. Use a transfer sheet without locking the wheels

Correct answer: A

Rationale: Locking the wheels on both the bed and stretcher is crucial for ensuring stability during the transfer process. This action is essential to prevent unexpected movement of the bed or stretcher, reducing the risk of injury to the client and facilitating a safe transfer. Adjusting the bed to a low position is important for the client's comfort and safety but does not directly address the immediate need for stability during the transfer. Asking the client to assist in the transfer may not be feasible immediately postoperatively, depending on their condition and the type of surgery they underwent. Using a transfer sheet without locking the wheels can introduce potential safety hazards as the bed or stretcher may move during the transfer, undermining the stability needed for a safe and effective transfer.

5. After repositioning a client who reports shortness of breath, which of the following actions should the nurse take next?

• A. Observe the rate, depth, and character of the client's respirations.
• B. Take the client’s blood pressure.
• C. Assess the client's pulse.
• D. Offer supplemental oxygen.

Correct answer: A

Rationale: Observing the rate, depth, and character of the client's respirations is crucial after repositioning a client experiencing shortness of breath. This action provides immediate information about the client's respiratory status. Checking blood pressure (Choice B) is not the priority in this situation, as assessing respirations is more urgent. Assessing the pulse (Choice C) is also important but does not provide direct information about the client's respiratory status. Offering supplemental oxygen (Choice D) may be necessary based on the assessment of respirations, but it should not be the first action taken without assessing the client's breathing pattern.

Similar Questions