Nursing Elites

1. A client with heart failure is being taught by a nurse on reducing daily sodium intake. Which factor is most crucial in determining the client’s ability to learn new dietary habits?

• A. The client's involvement in planning the change
• B. The cost of the dietary changes
• C. The availability of low-sodium foods
• D. The client’s previous dietary knowledge

Correct answer: D

Rationale: The client’s previous dietary knowledge is the most critical factor in determining the ability to learn new dietary habits. Understanding the client's existing dietary knowledge helps tailor the teaching to build upon what they already know. While client involvement in planning changes can increase adherence and motivation, the foundational knowledge is essential for effective learning. The cost of dietary changes and the availability of low-sodium foods are important considerations but not as crucial as the client's existing knowledge.

2. A healthcare professional is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the healthcare professional plan to initiate?

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

Correct answer: C

Rationale: Tuberculosis is transmitted through airborne particles, so airborne precautions are necessary to prevent the spread of the disease. Airborne precautions (Choice C) involve measures such as negative pressure rooms and N95 respirators to prevent the transmission of infectious agents that remain infectious over long distances when suspended in the air. Contact precautions (Choice A) are used for diseases that spread through direct contact with the patient or their environment. Droplet precautions (Choice B) are for diseases transmitted through respiratory droplets, typically over short distances. Protective environment (Choice D) is used for clients who are immunocompromised to protect them from environmental pathogens, not for diseases like tuberculosis that spread through the air.

3. A healthcare professional is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the healthcare professional provide to the assistive personnel?

• A. Collect at least 2 inches of formed stool.
• B. Wear sterile gloves while obtaining the specimen.
• C. Use a culturette for specimen collection.
• D. Record the date and time the stool was collected.

Correct answer: A

Rationale: To ensure accurate testing, a minimum amount of stool is required for specimen collection, typically at least 2 inches of formed stool. This amount provides an adequate sample for testing. Wearing sterile gloves is important for infection control but is not specifically required for stool specimen collection. Using a culturette is not typically necessary for collecting stool specimens. Recording the date and time the stool was collected is essential to ensure timely processing but does not directly impact the collection of the specimen itself.

4. When responding to a call light and finding a client on the bathroom floor, what should the nurse do FIRST?

• A. Check the client for injuries
• B. Call for additional help
• C. Move the client to a sitting position
• D. Assist the client back to bed

Correct answer: A

Rationale: Checking the client for injuries is the priority when finding them on the bathroom floor. This action ensures the client's safety as it allows for immediate assessment of any potential harm. Calling for help may be necessary, but assessing for injuries takes precedence to address any immediate threats to the client's well-being. Moving the client to a sitting position or assisting them back to bed should only be done after ensuring there are no serious injuries requiring prompt medical attention. Therefore, the correct first action is to check the client for injuries.

5. The LPN is caring for a client who has been placed in restraints. What is the most important action for the nurse to take?

• A. Ensure that the client’s circulation is checked every hour.
• B. Document the reason for the restraints every 4 hours.
• C. Provide range-of-motion exercises every 2 hours.
• D. Release the restraints every 2 hours for repositioning.

Correct answer: D

Rationale: The most crucial action for the nurse to take when caring for a client in restraints is to release the restraints every 2 hours for repositioning. This practice helps prevent complications such as pressure ulcers and impaired circulation by ensuring adequate blood flow and preventing skin breakdown. Checking the client's circulation every hour (Choice A) is important, but releasing the restraints for repositioning takes precedence to prevent serious complications. While documenting the reason for restraints (Choice B) is essential for legal and documentation purposes, it is not as critical as providing necessary care to the client's physical well-being. Providing range-of-motion exercises (Choice C) is beneficial for maintaining mobility but may not address the immediate risks associated with prolonged restraint use.

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