Nursing Elites

1. How does the home care nurse determine that a 78-year-old client is unable to remain in his current residence alone?

• A. The goals set by the client
• B. The learning level of the client
• C. Assessing the home environment
• D. The distractions in the client's home

Correct answer: C

Rationale: The correct answer is assessing the home environment. This process is vital in evaluating whether an elderly client can safely live independently. Factors like safety hazards and the client's ability to handle daily activities are considered during this assessment. Choices A, B, and D are incorrect because determining the client's ability to remain in his residence alone relies more on evaluating the home environment for safety and suitability rather than the client's goals, learning level, or distractions in the home.

2. A 12-year-old child is receiving a blood transfusion via an infusion pump and begins to complain of 'itchy' skin 15 minutes after the unit of blood is started. The child appears flushed. What action should the nurse take first?

• A. Apply lotion to the skin
• B. Stop the transfusion
• C. Inspect the infusion site
• D. Obtain the vital signs

Correct answer: B

Rationale: Stopping the transfusion immediately is crucial when signs of a transfusion reaction, such as itching and flushing, occur. This action is taken to prevent further exposure to the potentially harmful transfused blood. Applying lotion to the skin, inspecting the infusion site, or obtaining vital signs can be important but are secondary to stopping the transfusion to ensure the safety of the child. Applying lotion may not address the underlying issue of a possible transfusion reaction. Inspecting the infusion site and obtaining vital signs can be done after stopping the transfusion, as patient safety is the top priority in this situation.

3. A client post-coronary artery bypass graft (CABG) surgery is concerned about the risk of infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?

• A. Avoid touching the incision sites with bare hands.
• B. Take all prescribed antibiotics as directed.
• C. Report any signs of infection to the healthcare provider immediately.
• D. Keep the incision sites clean and dry.

Correct answer: D

Rationale: The correct answer is D: 'Keep the incision sites clean and dry.' After CABG surgery, maintaining the cleanliness and dryness of the incision sites is crucial to prevent infections. This practice reduces the risk of introducing harmful microorganisms to the surgical wound, promoting healing and preventing complications. Option A, while important, does not fully encompass the preventive measures necessary to avoid infections post-surgery. Option B is significant if antibiotics are prescribed, but ensuring cleanliness directly addresses infection prevention. Option C is reactive and focuses on addressing infection after it occurs, rather than proactively preventing it.

4. To accommodate a patient who is an Orthodox Jew, you would assure that her diet does not include which of the following?

• A. Any combination of meat and milk at the same meal
• B. Fish with scales
• C. Salmon
• D. Grape juice

Correct answer: A

Rationale: The correct answer is A. Orthodox Jewish dietary laws prohibit mixing meat and dairy in the same meal, so to accommodate an Orthodox Jew, you should ensure that their diet does not include any combination of meat and milk at the same meal. Choices B, C, and D are not prohibited in a kosher diet. Fish with scales, including salmon, are typically kosher, and grape juice is also permissible under kosher guidelines if certified. Therefore, options B, C, and D are acceptable in an Orthodox Jewish diet, while option A contradicts their dietary laws.

5. The practical nurse is caring for a client who had a total laryngectomy, left radical neck dissection, and tracheostomy. The client is receiving nasogastric tube feedings via an enteral pump. Today the rate of feeding is increased from 50 ml/hr to 75 ml/hr. What parameter should the PN use to evaluate the client's tolerance to the rate of the feeding?

• A. Daily weight
• B. Gastric residual volumes
• C. Bowel sounds
• D. Urinary and stool output

Correct answer: B

Rationale: Monitoring gastric residual volumes helps to assess how well the client is tolerating the increased feeding rate. High residuals may indicate delayed gastric emptying, which could lead to complications like aspiration. This helps in adjusting the feeding plan as necessary. Daily weight (Choice A) is not the most appropriate parameter to evaluate tolerance to feeding rate changes. Bowel sounds (Choice C) and urinary/stool output (Choice D) are important assessments but do not directly indicate tolerance to enteral feeding rate changes.

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