Nursing Elites

1. A nurse manager is discussing the responsibility of nurses caring for clients who have Clostridium difficile. Which of the following information should the nurse include in the teaching?

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

Correct answer: D

Rationale: The correct answer is D because having family members wear a gown and gloves when visiting a client with Clostridium difficile is essential to prevent the spread of infection. Options A, B, and C are incorrect. Negative air-flow systems are not necessary for preventing the spread of C. difficile. While alcohol-based hand sanitizers are effective for routine hand hygiene, they may not be sufficient for C. difficile. Cleaning contaminated surfaces with a phenol solution is not the most effective method for preventing the spread of C. difficile, as spores can be resistant to many disinfectants.

2. A client with a tracheostomy is experiencing increased secretions and labored breathing. What should the nurse do first?

• A. Administer a bronchodilator
• B. Suction the tracheostomy
• C. Encourage the client to cough
• D. Notify the provider

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy first. When a client with a tracheostomy is experiencing increased secretions and labored breathing, suctioning the tracheostomy is the priority intervention to clear the airway and improve breathing. Administering a bronchodilator (Choice A) may help with breathing but should come after ensuring the airway is clear. Encouraging the client to cough (Choice C) may not be effective in clearing secretions from the tracheostomy. Notifying the provider (Choice D) can be done after ensuring immediate airway clearance.

3. A nurse is collecting data from a client who is in severe pain. Which of the following questions should the nurse ask first?

• A. When did your pain start?
• B. How severe is your pain?
• C. What makes your pain worse?
• D. Where is your pain located?

Correct answer: D

Rationale: The nurse should first ask the client where the pain is located because identifying the location of the pain is crucial in determining the cause and appropriate treatment. This information helps in further assessment and diagnosis. Asking when the pain started (Choice A) may be important but determining the location provides more immediate insights. Inquiring about the severity of pain (Choice B) and what worsens it (Choice C) are also important but come after identifying the location to provide a comprehensive understanding of the client's condition.

4. What is the first step in preparing a blood transfusion?

• A. Administer the blood via IV push
• B. Verify the client's blood type before starting the transfusion
• C. Warm the blood to body temperature before administration
• D. Administer diuretics to prevent fluid overload

Correct answer: B

Rationale: The correct first step in preparing a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to ensure compatibility and prevent adverse reactions. Administering the blood via IV push (Choice A) is incorrect as it skips the essential step of verifying the blood type. Warming the blood to body temperature (Choice C) is important but comes after verifying the blood type. Administering diuretics (Choice D) is not part of the preparation process for a blood transfusion.

5. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home?

• A. Family members who smoke should be at least 10 ft away from the client when oxygen is in use
• B. Nail polish should not be used near a client who is receiving oxygen
• C. A 'No Smoking' sign should be placed on the front door
• D. Cotton bedding and clothing should be replaced with items made from wool

Correct answer: C

Rationale: The correct answer is C. Placing a 'No Smoking' sign on the front door is crucial for fire safety when using oxygen at home. Choice A is incorrect as family members who smoke should not be around the client when oxygen is in use, not just at a distance. Choice B is not directly related to oxygen safety. Choice D is also irrelevant as the type of bedding and clothing material does not impact oxygen safety.

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