Nursing Elites

1. A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?

• A. 'All of this equipment can be frightening.'
• B. 'The equipment is necessary to monitor your condition.'
• C. 'You should try to ignore the equipment.'
• D. 'Try to relax; the equipment is not harmful.'

Correct answer: A

Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.

2. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

• A. Carry a client's soiled linens out of the room in a mesh linen bag
• B. Place a client who has tuberculosis in a room with negative-pressure airflow
• C. Provide disposable plates and utensils for a client who is HIV-positive
• D. Dispose of a client's blood-saturated dressing in a biohazard bag

Correct answer: B

Rationale: A client who has tuberculosis requires airborne precautions, including placing the client in a room with negative-pressure airflow to reduce the risk of infection transmission. Choices A, C, and D are incorrect. Carrying soiled linens in a mesh bag, providing disposable plates and utensils for an HIV-positive client, and disposing of blood-saturated dressing in a biohazard bag do not specifically address preventing the spread of tuberculosis, which requires airborne precautions.

3. Which of the following manifestations confirms the presence of pediculosis capitis in students?

• A. Scratching the head more than usual
• B. Flakes evident on a student's shoulders
• C. Oval pattern occipital hair loss
• D. Whitish oval specks sticking to the hair

Correct answer: D

Rationale: The correct answer is D. Whitish oval specks sticking to the hair shaft are nits, which are a definitive sign of pediculosis capitis (head lice). A: Scratching the head more than usual is a common symptom but not confirmatory of head lice infestation. B: Flakes evident on a student's shoulders may indicate dandruff or dry scalp, not necessarily head lice. C: Oval pattern occipital hair loss is not a typical manifestation of pediculosis capitis.

4. A nurse prepares an injection of morphine to administer to a client who reports pain but asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take?

• A. Offer to assist the client who needs the bedpan.
• B. Administer the injection the other nurse prepared.
• C. Prepare another syringe and administer the injection.
• D. Tell the client who needs the bedpan to wait while the nurse gives someone else medication.

Correct answer: C

Rationale: The second nurse should prepare a new syringe and administer the medication to ensure proper and timely pain management. Administering another nurse's medication without preparation could lead to errors. Choice A is not the priority as the medication administration should take precedence. Choice B is not recommended as the second nurse should not administer medication prepared by another nurse. Choice D is inappropriate as patient needs should not be compromised for medication administration to another client.

5. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take?

• A. Divert the client’s attention
• B. Call for additional help from staff
• C. Document the planned action
• D. Re-assess the client's situation

Correct answer: D

Rationale: Re-assessing the client's situation before providing care is the most appropriate action in this scenario. By re-evaluating the client, the nurse can better understand the cause of the anxiety and tailor the care accordingly. Diverting the client's attention (Choice A) may not address the underlying issue causing anxiety. Calling for additional help (Choice B) is not the initial step required unless there is an urgent need. Documenting the planned action (Choice C) should come after reassessing the client to ensure accuracy and relevance.

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