Nursing Elites

1. What is the most important assessment for a patient post-surgery?

• A. Monitor vital signs
• B. Check surgical site for bleeding
• C. Check for abnormal breath sounds
• D. Check skin color

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs provide crucial information about a patient's physiological status, helping detect early signs of complications such as shock, bleeding, or infection. Checking the surgical site for bleeding is important but falls secondary to monitoring vital signs, which give a broader overview of the patient's condition. Checking for abnormal breath sounds and skin color are also important assessments, but they are not as immediate and general as monitoring vital signs in detecting various post-surgical complications.

2. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a private room with negative airflow.
• B. Wear an N95 respirator when caring for the client.
• C. Place the client in a positive pressure room.
• D. Maintain the client on droplet precautions.

Correct answer: A

Rationale: The correct answer is to place the client in a private room with negative airflow. This is crucial for preventing the spread of tuberculosis (TB) infection. Option B, wearing an N95 respirator when caring for the client, is important for staff protection but does not address the need for isolation precautions. Option C, placing the client in a positive pressure room, is incorrect as TB clients should be in negative pressure rooms to prevent the spread of airborne pathogens. Option D, maintaining the client on droplet precautions, is not sufficient for TB, which requires airborne precautions.

3. A nurse is caring for a client who has a Clostridium difficile infection. Which of the following precautions should the nurse implement?

• A. Place the client in a negative pressure room
• B. Wear an N95 respirator mask when entering the room
• C. Wear a gown and gloves when providing care to the client
• D. Place a face mask on the client

Correct answer: C

Rationale: The correct precaution to implement when caring for a client with Clostridium difficile infection is to wear a gown and gloves when providing care. Clostridium difficile is primarily spread through contact with feces, so wearing personal protective equipment like gowns and gloves is crucial in preventing the spread of the infection. Placing the client in a negative pressure room (Choice A) is not necessary for Clostridium difficile. While wearing an N95 respirator mask (Choice B) is important for airborne precautions, it is not required for Clostridium difficile. Placing a face mask on the client (Choice D) is not a standard precaution for preventing the spread of Clostridium difficile.

4. A nurse is preparing to administer an enema to a client. Which of the following actions should the nurse take?

• A. Place the client in a high-Fowler's position
• B. Assist the client to the left Sims' position
• C. Insert the enema tubing 2.5 cm (1 in) into the rectum
• D. Lubricate the tip of the enema tubing with petroleum jelly

Correct answer: B

Rationale: The correct answer is to assist the client to the left Sims' position when administering an enema. This position helps facilitate the flow of the enema solution into the rectum. Placing the client in a high-Fowler's position (Choice A) is not ideal for administering an enema. Inserting the enema tubing 2.5 cm (1 in) into the rectum (Choice C) is incorrect as it should be inserted 7.5-10 cm (3-4 in) for an adult. Lubricating the tip of the enema tubing with petroleum jelly (Choice D) is a correct step to ease insertion but is not the most critical action among the choices provided.

5. A client has a new prescription for alendronate. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime.
• B. Take this medication with food to reduce stomach upset.
• C. Remain upright for 30 minutes after taking this medication.
• D. Chew the medication for faster absorption.

Correct answer: C

Rationale: The correct instruction when taking alendronate is to remain upright for 30 minutes after administration. This helps prevent esophageal irritation, a known side effect of the medication. Option A is incorrect because alendronate should be taken in the morning on an empty stomach. Option B is incorrect as taking alendronate with food decreases its absorption. Option D is incorrect as alendronate should be swallowed whole with a full glass of water and not chewed.

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