Nursing Elites

1. When caring for a client who is on contact precautions, which of the following measures should the nurse include in the teaching?

• A. Remove the protective gown after leaving the client's room.
• B. Place the client in a room with negative pressure.
• C. Wear gloves when providing care to the client.
• D. Wear a mask when in the client's room.

Correct answer: C

Rationale: Contact precautions are used for clients with known or suspected infections that are spread by direct or indirect contact. The most important measure for healthcare workers when caring for a client on contact precautions is to wear gloves when providing care. This helps prevent the transmission of infectious agents between the client and the healthcare worker. Removing the protective gown after leaving the client's room, placing the client in a room with negative pressure, and wearing a mask when in the client's room are not specific to contact precautions and may not be necessary for all clients on contact precautions.

2. During a shift change, a nurse is receiving a report for an adult female client who is postoperative. Which of the following client information should the nurse report?

• A. High platelets
• B. Hypertension
• C. Lower platelets
• D. High temperatures

Correct answer: C

Rationale: Lower platelets can indicate a potential risk of bleeding in a postoperative client. Thrombocytopenia, or low platelet count, can lead to increased bleeding tendencies and should be promptly reported to the healthcare team for appropriate management. Monitoring platelet levels is crucial in postoperative care to prevent complications related to inadequate clotting ability.

3. What is the appropriate route of administration for insulin?

• A. Intramuscular
• B. Intradermal
• C. Subcutaneous
• D. Intravenous

Correct answer: C

Rationale: The appropriate route of administration for insulin is subcutaneous. Subcutaneous injections are commonly used for insulin administration due to the slower absorption rate compared to intramuscular or intravenous routes. This slower absorption rate allows for better control of blood glucose levels. Intramuscular administration is not ideal for insulin as it can lead to rapid absorption and fluctuations in blood sugar levels. Intradermal injections are shallow and used for skin testing rather than insulin administration. Intravenous administration of insulin is not recommended due to the rapid and unpredictable effects it can have on blood glucose levels.

4. A client is receiving discharge instructions from a healthcare provider after being prescribed albuterol for COPD. Which statement by the client indicates understanding of the teaching?

• A. Albuterol can increase my blood sugar levels.
• B. Albuterol can decrease my immune response.
• C. I can experience an increase in my heart rate while taking albuterol.
• D. I may develop mouth sores while taking albuterol.

Correct answer: C

Rationale: Albuterol is a bronchodilator commonly used to treat conditions like COPD. One of its common side effects is an increase in heart rate (tachycardia) due to its action on beta-2 receptors in the body. This statement by the client demonstrates an understanding of a potential side effect of albuterol, indicating comprehension of the discharge teaching provided by the healthcare provider.

5. A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?

• A. Instill 500 ml of solution through the NG tube.
• B. Insert a large-bore NG tube.
• C. Use a cold irrigation solution.
• D. Instruct the client to lie on their right side.

Correct answer: B

Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.

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