Nursing Elites

1. The census on the unit is 90 percent, and there are no private rooms available. An elderly client with influenza is admitted. Which of the following rooms would it be appropriate to assign this client?

• A. A double room with a client admitted for impetigo.
• B. A double room with another client with the same diagnosis.
• C. A four-bed room with three clients who have had orthopedic surgery.
• D. A double room with an elderly client with a diagnosis of chickenpox.

Correct answer: B

Rationale: When a private room is not an option, the best choice is to assign the elderly client with influenza to a double room with another client diagnosed with the same condition. This is ideal as droplet precautions would likely already be in place for the other client, reducing the risk of spreading the infection to other clients in the unit. Choice A is not appropriate as impetigo does not require the same precautions as influenza. Choice C is not ideal as orthopedic surgery does not involve respiratory precautions. Choice D is incorrect because chickenpox requires airborne precautions, which could pose a risk to the elderly client with influenza.

2. A client with a history of myocardial infarction (MI) is admitted with chest pain. Which laboratory test should the nurse expect to be ordered to determine if the client is experiencing another MI?

• A. Troponin
• B. Myoglobin
• C. CK-MB
• D. C-reactive protein

Correct answer: A

Rationale: Troponin is the most specific and sensitive laboratory test for detecting myocardial infarction (MI). It is released when there is damage to the heart muscle, making it a valuable marker for diagnosing another MI. Myoglobin and CK-MB can also be elevated in MI, but troponin is preferred due to its higher specificity. C-reactive protein is a marker of inflammation and not specific to MI.

3. Why is it most important to start intravenous infusions in the upper extremities rather than the lower extremities of adults?

• A. Superficial veins are more easily found in the feet and ankles.
• B. A decreased flow rate could lead to thrombosis formation.
• C. It is more challenging to move a cannulated extremity when using the leg or foot.
• D. Veins in the feet and ankles are located deep, making the procedure more painful.

Correct answer: B

Rationale: The most critical reason for initiating intravenous infusions in the upper extremities of adults is to reduce the risk of thrombosis (B). Venous return is typically better in the upper extremities, decreasing the likelihood of thrombus formation, which could be life-threatening if dislodged. Although superficial veins are easily found in the feet and ankles (A), this is not the primary reason for choosing the upper extremities. Handling a leg or foot with an IV (C) is not significantly more challenging than handling an arm or hand. The depth of veins in the feet and ankles (D) does not primarily determine the site for IV placement.

4. A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?

• A. Increase fluid intake to 3 liters per day.
• B. Limit sodium intake to 2 grams per day.
• C. Avoid foods high in potassium.
• D. Increase protein intake to promote healing.

Correct answer: B

Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Excessive sodium can lead to fluid retention, worsening heart failure symptoms. Increasing fluid intake (A) can further exacerbate fluid overload in heart failure patients. Avoiding foods high in potassium (C) is not necessary unless the client has hyperkalemia; in heart failure, potassium restriction is not a primary dietary concern. Increasing protein intake (D) is not the priority for heart failure management; focusing on sodium restriction is more beneficial.

5. A client is 2 days post-op from thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain as a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action?

• A. Instruct the client to use guided imagery and slow rhythmic breathing
• B. Provide at least 20 minutes of back massage and gentle effleurage
• C. Encourage the client to watch TV
• D. Place a hot water circulation device, such as an Aqua K pad, to the operative site

Correct answer: A

Rationale: In this scenario, since no additional pain medication is available, the nurse should recommend non-pharmacological pain management techniques. Guided imagery and slow rhythmic breathing can help the client manage incisional pain effectively. These techniques can provide distraction and relaxation, potentially reducing the perception of pain without the need for additional medication.

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