Nursing Elites

1. Which infection control measure is the priority for the nurse to implement in the care provided for a child admitted to the hospital with bacterial meningitis?

• A. Place the child in a private room
• B. Gowns and masks must be worn by all personnel in the child's room
• C. Visitors are restricted to parents only
• D. Hand washing is required by all personnel and visitors having contact with the child

Correct answer: B

Rationale: The priority control measure for the nurse to implement in caring for a child with bacterial meningitis is ensuring that gowns and masks are worn by all personnel in the child's room. This measure is crucial as the child with bacterial meningitis is contagious for at least 24 hours after starting antibiotics, necessitating airborne precautions to prevent the spread of infection to healthcare workers and other patients. Placing the child in a private room (Choice A) is important but secondary to preventing infection transmission. Restricting visitors to parents only (Choice C) is also significant but not as critical as ensuring proper infection control measures. While hand washing (Choice D) is essential, the immediate need to prevent airborne transmission in the child's room takes precedence.

2. A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:

• A. Obtaining Intake and Output.
• B. Frequent lung assessments.
• C. Vital signs every shift.
• D. Monitoring the IV site for infiltration.

Correct answer: D

Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.

3. Which of the following microorganisms is easily transmitted from client to client on the hands of healthcare workers?

• A. mycobacterium tuberculosis
• B. clostridium tetani
• C. staphylococcus aureus
• D. human immunodeficiency virus

Correct answer: C

Rationale: The correct answer is staphylococcus aureus. Staphylococcus aureus microorganisms are ubiquitous and easily transmitted by healthcare workers who fail to conduct routine hand washing between clients. Staphylococcus aureus can reside on the skin and be transferred from one client to another if proper hand hygiene is not practiced. Mycobacterium tuberculosis is mainly transmitted through the airborne route, clostridium tetani is usually acquired through exposure to soil or dirt contaminated with tetanus spores, and human immunodeficiency virus is not easily transmitted through casual contact or on the hands of healthcare workers.

4. A client had a colostomy done one day ago. Which of the following is an abnormal finding when assessing the stoma?

• A. mild edema
• B. minimal bleeding
• C. rose color
• D. dark red color

Correct answer: D

Rationale: A dark red color is an abnormal finding when assessing the stoma as it indicates inadequate blood supply, possibly due to ischemia. Mild edema, minimal bleeding, and a rose color are expected findings one day post colostomy surgery. Mild edema can be present due to tissue trauma and inflammation, minimal bleeding can occur initially, and a healthy stoma typically appears pink to red, known as a rose color, indicating good blood supply and tissue perfusion. Therefore, the dark red color is the abnormal finding in this scenario.

5. Is head lag expected to be resolved by 4 months of age? Continuing head lag at 6 months of age may indicate?

• A. Dizziness and orthostatic hypotension.
• B. Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
• C. Drowsiness, lethargy, and fatigue.
• D. Neuropathy and tingling in the extremities.

Correct answer: B

Rationale: Head lag is a developmental milestone that should be resolved by 4 months of age. Continuing head lag at 6 months of age may indicate potential developmental delays or muscle weakness. The correct answer, 'Nausea, vomiting, diarrhea, or constipation, and stomach cramps,' reflects symptoms that could be associated with developmental delays or underlying health conditions. Dizziness and orthostatic hypotension (Choice A) are unlikely to be directly related to head lag. Choices C and D present symptoms that are unrelated to the issue of continued head lag at 6 months of age.

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