Nursing Elites

1. The nurse is teaching a class on child care to new parents. Which instruction should be included about the prevention of rotavirus infection in infants who are starting to eat foods?

• A. Keep house pets away from the food preparation area
• B. Avoid feeding infants fresh fruits
• C. Use only lactose-free formulas
• D. Wash hands before any food preparation

Correct answer: D

Rationale: The correct answer is D: Wash hands before any food preparation. Rotavirus is a highly contagious virus that can be prevented by maintaining proper hygiene. Washing hands before handling food can help prevent the spread of infections, including rotavirus. Choices A, B, and C are incorrect because while they are good practices for general hygiene and infant care, they are not specifically targeted at preventing rotavirus infection.

2. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rates the pain 5 on a pain scale of 0 to 10. The client’s blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply)

• A. Administer the scheduled daily dose of lisinopril.
• B. Assess the client for postural hypotension.
• C. Notify the healthcare provider immediately.
• D. Provide a PRN dose of acetaminophen for the headache.

Correct answer: A

Rationale: In this scenario, the client's blood pressure of 142/89 is within an acceptable range for someone with a history of hypertension. The client's headache with a pain rating of 5 does not warrant an immediate notification to the healthcare provider. Administering the scheduled dose of lisinopril is appropriate to manage the client's hypertension. Assessing the client for postural hypotension is relevant due to the client's age and hypertension history. Providing a PRN dose of acetaminophen for the headache is not necessary at this point as the pain level is moderate and can be managed with other interventions.

3. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client’s statements?

• A. Remind the client that it is also important to schedule an annual mammogram.
• B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure.
• C. Encourage the client to perform BSE 2 to 3 days after her menstrual period ends.
• D. Instruct the client to continue with her regular monthly exams as she is doing.

Correct answer: C

Rationale: The correct answer is to encourage the client to perform BSE 2 to 3 days after her menstrual period ends. This timing is recommended because breasts are least tender and swollen at this point, making it easier to detect any abnormalities. Choice A is incorrect because while scheduling an annual mammogram is important, it is not the immediate action needed based on the client's statements. Choice B is incorrect as the client's BSE technique timing needs adjustment rather than an in-depth review by a nurse practitioner. Choice D is incorrect because the client should modify the timing of the BSE for better effectiveness.

4. The nurse working on a mental health unit is prioritizing nursing care activities due to a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened, and morning medications need to be prepared. Which plan is best for the nurse to implement?

• A. Wake all the clients and instruct them to go to the dining area for medication administration
• B. Explain to the clients that it will be necessary to cooperate until another RN arrives
• C. Ask the PN to administer medications as clients are awakened so both nurses are available
• D. Allow the clients to sleep until a third staff person can assist with unit activities

Correct answer: C

Rationale: The best plan for the nurse to implement is to ask the PN to administer medications as clients are awakened. This approach ensures that medication administration and client care are efficiently managed despite the staffing shortage. Option A is incorrect as it may disrupt the workflow and create unnecessary chaos. Option B is not the best choice as it does not address the immediate need for medication administration. Option D is not ideal as it delays client care until additional staff arrive, potentially compromising patient safety and timely medication administration.

5. A man calls the hospital and asks to talk with the nurse about his girlfriend who was extremely intoxicated on admission and is receiving services for detoxification. He knows that she is in the facility and asks the nurse about her condition. What is the nurse's best response?

• A. ''I can only report that the client is in satisfactory condition.''
• B. ''Let me give you the telephone number for her room.''
• C. ''I cannot acknowledge if a client is here or not.''
• D. ''I will have the nurse who is working with her call you.''

Correct answer: C

Rationale: The nurse must adhere to confidentiality rules and cannot confirm the presence or condition of the client. Choice A is incorrect because disclosing the client's condition breaches confidentiality. Choice B is wrong as it reveals the client's room number, which is also a breach of confidentiality. Choice D is not the best response as it involves sharing information about the client without verifying the caller's identity or relationship to the client.

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