Nursing Elites

1. A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

• A. You should receive a pneumococcal vaccine when you are 65 years old.
• B. You should receive a shingles vaccine when you are 70 years old.
• C. You should receive a tetanus booster every 5 years.
• D. You should have an eye examination every 2 years.

Correct answer: A

Rationale: The correct answer is A. The CDC recommends a pneumococcal vaccine for all adults aged 65 years and older. This vaccine helps protect against serious pneumococcal disease. Choice B is incorrect as the shingles vaccine is recommended for adults aged 50 years and older, not specifically at 70 years. Choice C is incorrect because a tetanus booster is recommended every 10 years, not every 5 years. Choice D is incorrect as the general recommendation for eye examinations in older adults is annually, not every 2 years.

2.

• A. The RN tells the client he is not allowed to leave until the physician has released him.
• B. The RN asks the client why he wishes to leave.
• C. The RN asks the client to explain what he understands about his medical diagnosis.
• D. The RN asks the client to sign an against medical advice discharge form.

Correct answer: A

Rationale: Verbal or physical detainment of a client who desires to leave the institution is false imprisonment.

3. A nurse is discussing the responsibility of caring for clients with clostridium difficile infection. Which of the following information should the nurse include in the teaching?

• A. Have family members wear a gown and gloves when visiting.
• B. Clean contaminated surfaces in the client's room with a bleach solution.
• C. Use alcohol-based hand sanitizer when leaving the client's room.
• D. Assign the client to a room with a private bathroom.

Correct answer: A

Rationale: When caring for clients with clostridium difficile infection, it is important to prevent the spread of the bacteria. Having family members wear a gown and gloves when visiting helps reduce the risk of transmission. Cleaning contaminated surfaces with a bleach solution, not phenol, is recommended to effectively kill the C. difficile spores. Using alcohol-based hand sanitizer is not sufficient, as it may not be effective against C. difficile spores. Assigning the client to a room with a private bathroom is more beneficial than a negative airflow system, as it helps prevent the spread of bacteria to other clients.

4.

• A. The RN tells the client he is not allowed to leave until the physician has released him.
• B. The RN asks the client why he wishes to leave.
• C. The RN asks the client to explain what he understands about his medical diagnosis.
• D. The RN asks the client to sign an against medical advice discharge form.

Correct answer: A

Rationale: The RN tells the client he is not allowed to leave until the physician has released him would be considered false imprisonment.

5. An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to

• A. give a bolus of 50% dextrose.
• B. insert a large-bore IV catheter.
• C. initiate oxygen via nasal cannula.
• D. administer glargine (Lantus) insulin.

Correct answer: B

Rationale: In a patient with hyperosmolar hyperglycemic syndrome (HHS), severe dehydration and electrolyte imbalances are common. To address these issues, the priority intervention is to insert a large-bore IV catheter for fluid resuscitation and electrolyte replacement. Giving a bolus of 50% dextrose would worsen the hyperglycemia. Initiating oxygen via nasal cannula may be beneficial for respiratory support but is not the priority in this scenario. Administering glargine (Lantus) insulin is not the initial treatment for HHS as it does not address the underlying severe dehydration and electrolyte imbalances.

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