Nursing Elites

1. Which of the following is the most effective way to prevent the spread of infection in a healthcare setting?

• A. Using sterile gloves
• B. Wearing a face mask
• C. Performing hand hygiene
• D. Using disposable equipment

Correct answer: C

Rationale: Performing hand hygiene is the most effective way to prevent the spread of infection in a healthcare setting. Hand hygiene helps remove pathogens that could be transmitted through direct contact, making it a crucial practice in infection control. While using sterile gloves and disposable equipment are important in certain situations, they do not address the potential transmission of pathogens through direct contact, unlike hand hygiene. Wearing a face mask is important for respiratory precautions but may not be as effective as hand hygiene in preventing the spread of infections through direct contact.

2. The home health PN suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the PN to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: The most important action for the PN to take in this situation is to report the findings to the supervisor for referral to adult protective services. Suspected elder abuse must be reported promptly to ensure the safety and protection of the client. Documenting the lacerations in the client's record is important but not as critical as reporting the suspected abuse. Asking the daughter who is the potential abuser may not yield accurate information and could compromise the safety of the client. Applying dressings to the wounds is a lower priority compared to addressing the suspected elder abuse.

3. The PN administered darbepoetin alfa to a client with chronic kidney disease (CKD). Which serum laboratory value should the PN monitor to assess the effectiveness of this drug?

• A. Calcium
• B. Phosphorus
• C. Hemoglobin
• D. White blood cell count

Correct answer: C

Rationale: Darbepoetin alfa is used to stimulate red blood cell production in clients with CKD. Monitoring hemoglobin levels is essential to assess the effectiveness of the treatment and to adjust the dosage to avoid complications such as hypertension or thrombosis. Monitoring calcium (Choice A), phosphorus (Choice B), or white blood cell count (Choice D) is not directly related to the effectiveness of darbepoetin alfa in treating anemia associated with CKD.

4. A client post-mastectomy is concerned about the risk of lymphedema. What should the nurse include in the discharge instructions to minimize this risk?

• A. Wear compression garments on the affected arm.
• B. Avoid venipunctures and blood pressure measurements on the affected arm.
• C. Perform vigorous exercises to strengthen the affected arm.
• D. Keep the affected arm elevated at all times.

Correct answer: B

Rationale: To minimize the risk of lymphedema after a mastectomy, it is essential to instruct the client to avoid venipunctures and blood pressure measurements on the affected arm. These procedures can lead to trauma or impede lymphatic flow, increasing the risk of lymphedema. Wearing compression garments helps manage lymphedema but is not preventive. Performing vigorous exercises can strain the affected arm and increase the risk of lymphedema. Keeping the affected arm elevated at all times is unnecessary and not an effective preventive measure against lymphedema.

5. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the nurse who is taking the client's vital signs. What action should the nurse implement?

• A. Notify the healthcare provider or charge nurse immediately
• B. Offer to reschedule the treatment for the following week
• C. Plan to monitor the client's vital signs every 30 minutes
• D. Reinforce the need for extra rest periods and plenty of sleep

Correct answer: D

Rationale: Fatigue is a common side effect of radiation therapy. In this scenario, the appropriate action for the nurse to take is to reinforce the importance of rest and adequate sleep. It is crucial to address the client's increasing fatigue by promoting self-care strategies such as additional rest periods and ensuring plenty of sleep. Rescheduling the treatment is not necessary for fatigue, and vital sign monitoring every 30 minutes may not directly address the client's reported symptom. Notifying the healthcare provider or charge nurse immediately is not the first-line intervention for increasing fatigue, as this symptom can be managed through education and self-care recommendations.

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