Nursing Elites

1. By rolling contaminated gloves inside-out, the healthcare professional is affecting which step in the chain of infection?

• A. Mode of transmission
• B. Portal of entry
• C. Reservoir
• D. Portal of exit

Correct answer: A

Rationale: When contaminated gloves are rolled inside-out, they are serving as a mode of transmission by carrying pathogens from the reservoir's portal of exit to a new portal of entry. This action increases the risk of transmitting infections from one person to another, emphasizing the importance of proper glove removal techniques to prevent the spread of pathogens. Choices B, C, and D are incorrect in this context. Portal of entry refers to the route through which a pathogen enters a susceptible host, reservoir is the habitat where the pathogen lives, grows, and multiplies, and portal of exit is the path through which a pathogen leaves its host.

2. What action should the nurse implement to prepare a client for the potential side effects of a newly prescribed medication?

• A. Assess the client for health alterations that may be impacted by the effects of the medication
• B. Teach the client how to administer the medication to promote the best absorption
• C. Administer a half dose and observe the client for side effects before administering a full dosage
• D. Encourage the client to drink plenty of fluids to promote effective drug distribution

Correct answer: A

Rationale: Before initiating a new medication, the nurse should conduct a thorough assessment of the client to identify any pre-existing health conditions or risk factors that could be affected by the medication. This assessment helps in establishing a baseline for monitoring potential side effects and determining the medication's appropriateness for the client. Choice B is incorrect as teaching the client how to administer the medication does not directly address preparing for potential side effects. Choice C is incorrect because administering a half dose without a proper assessment could be unsafe. Choice D is incorrect as encouraging fluid intake is not directly related to preparing for potential side effects of a medication.

3. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

• A. Perform cough and deep breathing exercises hourly.
• B. Turn from side to side in bed at least every 2 hours.
• C. Dorsiflex and plantarflex the feet 10 times each hour.
• D. Drink approximately 4 ounces of water every hour.

Correct answer: C

Rationale: The most crucial instruction for a client with limited mobility to prevent venous thrombosis is to perform dorsiflexion and plantarflexion of the feet 10 times each hour. These exercises help promote venous return, reducing the risk of thrombosis by preventing blood stasis in the lower extremities. While other measures like turning in bed and staying hydrated are beneficial, promoting venous return through foot exercises is the priority in preventing venous thrombosis in clients with limited mobility. Dorsiflexion and plantarflexion directly target the calf muscle pump, aiding in the circulation of blood back to the heart and preventing clot formation. The other options, such as cough and deep breathing exercises, turning in bed, and hydration, are important for overall health but do not directly address venous stasis and thrombosis prevention in the same way as foot exercises.

4. A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?

• A. Encourage increased fluid intake.
• B. Place the client in a high Fowler's position.
• C. Measure the client's intake and output.
• D. Restrict dietary sodium intake.

Correct answer: D

Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.

5. A male healthcare provider is assigned to care for a female Muslim client. When the provider offers to bathe the client, the client requests that a female healthcare provider perform this task. How should the male healthcare provider respond?

• A. May I ask a female colleague to help you with your personal hygiene?
• B. I will ask one of the female healthcare providers to bathe you.
• C. A staff member on the next shift will help you.
• D. I will keep you draped and hand you the supplies as you need them.

Correct answer: B

Rationale: The most culturally sensitive response is for the male healthcare provider to ask one of the female healthcare providers to bathe the client. This approach respects the client's cultural and spiritual preferences by ensuring that their modesty and beliefs are honored during the care process. Choice A is incorrect as it puts the responsibility on the client to seek help, while the provider should take the initiative to arrange for appropriate care. Choice C is incorrect as it delays the assistance unnecessarily. Choice D, although helpful in maintaining modesty, does not address the client's request for a female healthcare provider to perform the task.

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