Nursing Elites

1. A nurse is planning care for a client who has tuberculosis. Which of the following actions should the nurse take to prevent the transmission of the disease?

• A. Place the client in droplet isolation.
• B. Place the client in airborne isolation.
• C. Wear a surgical mask when providing care to the client.
• D. Keep the client's door closed at all times.

Correct answer: B

Rationale: The correct answer is B: 'Place the client in airborne isolation.' Tuberculosis is an airborne disease transmitted through droplet nuclei. Placing the client in airborne isolation helps prevent the spread of the disease to others. Choice A, placing the client in droplet isolation, is incorrect because tuberculosis is not transmitted through large droplets. Choice C, wearing a surgical mask when providing care to the client, is not sufficient as airborne precautions are necessary. Choice D, keeping the client's door closed at all times, does not directly address the prevention of disease transmission in this case.

2. A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Blood glucose of 110 mg/dL.
• B. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
• C. WBC count of 6,500/mm3.
• D. Temperature of 37.3°C (99.1°F).

Correct answer: B

Rationale: A weight loss of 0.5 kg (1.1 lb) in 24 hours may indicate dehydration or malnutrition, which are critical concerns for a client receiving total parenteral nutrition (TPN). Therefore, the nurse should report this finding to the provider. Elevated blood glucose levels (Choice A) can be managed by adjusting TPN components, WBC count (Choice C) and a slightly elevated temperature (Choice D) are not directly related to TPN administration and may not require immediate intervention.

3. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following activities should the toddler participate?

• A. Looking at alphabet flashcards
• B. Playing with a large plastic truck
• C. Using scissors to cut out paper shapes
• D. Watching a cartoon in the dayroom

Correct answer: B

Rationale: The correct answer is playing with a large plastic truck. This activity is suitable for toddlers as it promotes their development, encourages fine motor skills, and provides an opportunity for imaginative play. Looking at alphabet flashcards may be more suitable for older children who are learning letters and words. Using scissors to cut out paper shapes may pose a safety risk for a toddler, as they may not have the dexterity or understanding required for this activity. Watching a cartoon in the dayroom is a passive activity and does not actively engage the toddler in physical or cognitive development.

4. A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?

• A. Tell the client that their delusions are not real
• B. Encourage the client to explore the meaning behind their delusions
• C. Focus on the client's feelings rather than the delusions
• D. Challenge the client's delusions directly

Correct answer: C

Rationale: In caring for a client with schizophrenia experiencing delusions, it is essential to focus on the client's feelings rather than directly addressing or challenging the delusions. By focusing on the client's emotions, the nurse can build trust and rapport without reinforcing the delusions. Choice A is incorrect because directly telling the client that their delusions are not real may lead to confrontation or mistrust. Choice B is incorrect as encouraging exploration of the delusions may further validate them. Choice D is incorrect because challenging the client's delusions can escalate the situation and damage the therapeutic relationship.

5. A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following actions should the provider take?

• A. Insert the needle at a 90-degree angle
• B. Insert the needle at a 45-degree angle
• C. Inject the medication slowly after aspiration
• D. Massage the site after injection

Correct answer: A

Rationale: Correct answer: When administering an intramuscular injection, the needle should be inserted at a 90-degree angle to ensure proper delivery of the medication into the muscle tissue. Option B is incorrect because a 45-degree angle is typically used for subcutaneous injections, not intramuscular. Option C is incorrect as aspiration is not recommended for intramuscular injections. Option D is incorrect as massaging the site after an intramuscular injection can cause tissue damage or interfere with the absorption of the medication.

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