Nursing Elites

1. The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?

• A. Defer the bath until evening and pass on the information to the next shift.
• B. Tell the patient that daily morning baths are part of the 'normal' routine.
• C. Explain the importance of maintaining morning hygiene practices.
• D. Cancel hygiene for the day and attempt again in the morning.

Correct answer: A

Rationale: The best action by the nurse is to respect the patient's preference and autonomy. Defer the bath until evening to allow the patient to follow their usual hygiene routine. Passing on the information to the next shift ensures continuity of care. Choice B is incorrect because it disregards the patient's preference and autonomy. Choice C, while important, does not address the patient's immediate concern. Choice D is incorrect as it does not respect the patient's wishes and may lead to further resistance to bathing.

2. A client with rheumatoid arthritis is prescribed methotrexate. What information should the LPN include when teaching the client about this medication?

• A. Avoid exposure to sunlight.
• B. Take the medication with food.
• C. Increase fluid intake while on this medication.
• D. Report any signs of infection to the healthcare provider immediately.

Correct answer: D

Rationale: The correct answer is D: 'Report any signs of infection to the healthcare provider immediately.' Methotrexate is an immunosuppressant medication commonly used to treat rheumatoid arthritis. It can lower the immune system's ability to fight infections, making it crucial for clients to promptly report any signs of infection to prevent serious complications. Choices A, B, and C are incorrect because avoiding sunlight, taking the medication with food, and increasing fluid intake are not specific to methotrexate therapy and are not primary concerns associated with this medication.

3. While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?

• A. Remove the gloves carefully and follow with hand hygiene
• B. Change gloves and continue
• C. Wash hands immediately without removing gloves
• D. Report the incident to the supervisor

Correct answer: A

Rationale: After completing the task, the nurse should remove the gloves carefully and follow with hand hygiene. This practice is crucial to prevent the transmission of any potential pathogens, maintain cleanliness, and reduce the risk of infection. Changing gloves and continuing without proper hand hygiene may lead to contamination. Washing hands immediately without removing gloves is not recommended as it does not ensure thorough hand hygiene. Reporting the incident to the supervisor should be done if there are specific protocols in place for such incidents, but immediate hand hygiene is the priority in this scenario to ensure patient and nurse safety.

4. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?

• A. Screening groups of older adults in nursing care facilities for early influenza manifestations
• B. Promoting hand hygiene to prevent the spread of influenza
• C. Administering influenza vaccinations
• D. Educating about the importance of healthy lifestyle choices to prevent influenza

Correct answer: A

Rationale: The correct answer is A. Secondary prevention aims to detect and address health issues early. Screening older adults in nursing care facilities for early influenza manifestations is an example of secondary prevention by identifying cases at an early stage. Choice B, promoting hand hygiene, is a form of primary prevention that aims to prevent the occurrence of influenza. Choice C, administering influenza vaccinations, is a form of primary prevention as well, focusing on preventing the disease before it occurs. Choice D, educating about healthy lifestyle choices, is more related to health promotion and primary prevention rather than secondary prevention.

5. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the nurse include?

• A. “Use full-length side rails on the client’s bed.”
• B. “Check on the client frequently while they are in the restroom.”
• C. “Encourage physical activity throughout the day to expend energy.”
• D. “Remove clocks from the client’s room.”

Correct answer: C

Rationale: Encouraging physical activity is an effective non-restraint intervention for managing confused clients. It helps reduce agitation, promotes circulation, and may decrease the need for restraints. Choice A is incorrect as using full-length side rails can potentially restrict a client's movement, which is counterproductive to avoiding restraints. Choice B, while emphasizing monitoring, does not directly address alternatives to restraint use. Choice D is also incorrect as removing clocks from the client's room does not directly address managing confusion and reducing the need for restraints.

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