Nursing Elites

1. A nurse is providing teaching to a newly licensed nurse about the care of a client who has MRSA. Which of the following statements by the newly licensed nurse indicates an understanding of teaching?

• A. I will place the client in a private room
• B. I will tell the client’s visitors to wear a mask when they are within 3 feet of the client
• C. I will remove my gown after leaving the client’s room
• D. I will wear an N95 respirator mask when caring for the client

Correct answer: A

Rationale: The correct answer is A: 'I will place the client in a private room.' Placing the client in a private room helps prevent the spread of MRSA, a contact precaution. Choice B is incorrect because visitors should be following standard precautions for MRSA, not just wearing a mask within a specific distance. Choice C is incorrect as the gown should be removed before exiting the client's room to prevent the spread of MRSA. Choice D is incorrect as an N95 respirator mask is not typically required for the care of a client with MRSA; standard precautions are usually sufficient.

2. A hospitalized client needs a chest x-ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client’s room, the priority action is to:

• A. Check the client’s identification bracelet
• B. Inform the client about the procedure
• C. Prepare the client for transport
• D. Verify the x-ray order

Correct answer: A

Rationale: The correct action to take when a transporter arrives to take a hospitalized client for a procedure is to check the client's identification bracelet. This step is crucial to prevent errors and ensure that the correct patient is receiving the intended procedure. Informing the client about the procedure and preparing them for transport are important steps in the process, but verifying the client's identity takes precedence to ensure patient safety. Verifying the x-ray order, though important, is not the priority action when the transporter arrives; confirming the patient's identity is essential before proceeding with any procedures.

3. The nurse is caring for a client with a tracheostomy who is unable to clear secretions by coughing. What is the most appropriate action for the nurse to take?

• A. Encourage the client to take deep breaths.
• B. Provide humidified oxygen via tracheostomy collar.
• C. Suction the tracheostomy tube as needed.
• D. Change the tracheostomy dressing daily.

Correct answer: C

Rationale: Suctioning the tracheostomy tube as needed is the most appropriate action in this scenario. When a client with a tracheostomy is unable to clear secretions by coughing, suctioning helps remove the excess secretions from the airway, ensuring proper breathing. Encouraging deep breaths (Choice A) may not effectively address the immediate need to clear secretions. Providing humidified oxygen (Choice B) can help with oxygenation but does not directly address the issue of clearing secretions. Changing the tracheostomy dressing daily (Choice D) is important for maintaining cleanliness but is not the priority when the client is unable to clear secretions.

4. When teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses, what should the charge nurse instruct as the initial response in CPR?

• A. Confirm unresponsiveness
• B. Check for a pulse
• C. Begin chest compressions
• D. Call for emergency help

Correct answer: A

Rationale: The correct initial response in CPR is to confirm unresponsiveness. This step is crucial to ensure that the person actually needs CPR before proceeding with further actions. Checking for unresponsiveness is essential to determine if the individual is in need of immediate assistance. Checking for a pulse or beginning chest compressions without confirming unresponsiveness could waste valuable time and potentially harm the individual. Calling for emergency help is important, but it should follow the confirmation of unresponsiveness to ensure timely activation of emergency services.

5. A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What is the priority nursing action for the LPN/LVN?

• A. Administer insulin as prescribed.
• B. Administer oral hypoglycemic agents.
• C. Monitor blood glucose levels frequently.
• D. Provide a high-calorie diet.

Correct answer: A

Rationale: The correct answer is to administer insulin as prescribed. When a client with diabetes mellitus presents with a critically high blood glucose level like 600 mg/dL, the priority action is to lower the blood glucose level promptly to prevent complications. Insulin is the appropriate medication to rapidly reduce high blood glucose levels. Administering oral hypoglycemic agents may not act quickly enough in this critical situation. While monitoring blood glucose levels frequently is important, immediate intervention to lower the high blood glucose level takes precedence. Providing a high-calorie diet is contraindicated in this scenario as it would further elevate the blood glucose level.

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