Nursing Elites

1. The nurse uses prioritization to determine all of the following except:

• A. time allotment for certain tasks.
• B. appropriate interventions.
• C. treatment procedures.
• D. the need for client education.

Correct answer: C

Rationale: The correct answer is C: "treatment procedures." Prioritization in nursing involves determining the order of importance or urgency of tasks. Treatment procedures are standards of care that need to be followed as defined by the facility or nursing unit. They are not typically subject to prioritization but are mandatory based on established protocols. Time allotment for certain tasks, appropriate interventions, and the need for client education are all aspects that can be influenced by prioritization. For instance, prioritizing tasks helps in managing time effectively, selecting the most suitable interventions, and identifying the necessity for client education as part of the care plan.

2. Which of the following might be an appropriate nursing diagnosis for an epileptic client?

• A. Dysreflexia
• B. Risk for Injury
• C. Urinary Retention
• D. Unbalanced Nutrition

Correct answer: B

Rationale: The correct nursing diagnosis for an epileptic client would be 'Risk for Injury' as the client is prone to injuries during seizure activity, such as head trauma from falls. Epilepsy does not typically cause dysreflexia. While urinary retention may occur during or after a seizure, it is not a common nursing diagnosis related to epilepsy. 'Unbalanced Nutrition' is not a priority nursing diagnosis for an epileptic client compared to the immediate risk of injury during seizures.

3. If a visitor accidentally knocks over a plastic pleural drainage system connected to a client, causing it to crack, what should the nurse do first?

• A. Observe the client's response.
• B. Notify the physician.
• C. Change the drainage system.
• D. Observe for leaks.

Correct answer: C

Rationale: When a pleural drainage system is cracked, the nurse's initial action should be to change the drainage system. This is essential to prevent potential complications like air leaks or infections. While observing the client's response and checking for leaks are important steps, they are secondary to addressing the immediate issue of the cracked system. Notifying the physician, though necessary, can be carried out once the primary concern of the damaged system is resolved.

4. A case management clinical pathway for congestive heart failure might include all of the following except:

• A. physician follow-up appointments with transportation
• B. client education regarding medication use
• C. a nutritional consult for diet review and accommodation
• D. insurance review for reimbursement

Correct answer: D

Rationale: In a case management clinical pathway for congestive heart failure, the focus is on providing medical care and support to the patient. Choices A, B, and C are integral parts of managing congestive heart failure. Physician follow-up appointments with transportation ensure continuity of care, client education about medication use is crucial for adherence, and a nutritional consult helps in managing the patient's diet. However, insurance review for reimbursement is not typically part of the clinical pathway as it pertains to financial aspects and is usually handled by billing departments or external agencies. Therefore, the correct answer is 'insurance review for reimbursement.'

5. Which of the following clients requires airborne precautions?

• A. a client with fever, chills, vomiting, and diarrhea
• B. a client suspected of varicella (chickenpox)
• C. a client with abdominal pain and purpura
• D. a client diagnosed with AIDS

Correct answer: B

Rationale: The correct answer is 'a client suspected of varicella (chickenpox).' Chickenpox is an acute, infectious airborne illness that requires airborne precautions, including wearing a respirator mask for direct contact with the patient. Choices A, C, and D do not typically require airborne precautions. Choice A describes symptoms that may indicate a gastrointestinal infection but do not require airborne precautions. Choice C mentions abdominal pain and purpura, which are not specific to an airborne illness. Choice D, a client diagnosed with AIDS, does not necessitate airborne precautions unless there are additional infectious conditions present that require such measures.

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