Nursing Elites

1. When should the nurse plan to collect a sputum specimen for culture and sensitivity as ordered by a client's provider?

• A. In the morning upon rising.
• B. Immediately after the client eats breakfast.
• C. Before the client goes to bed.
• D. After the client has had a drink of water.

Correct answer: A

Rationale: The correct time to collect a sputum specimen for culture and sensitivity is in the morning upon rising. This timing ensures the most concentrated sample as sputum produced overnight tends to accumulate and sit in the airways, providing a quality sample for testing. Collecting the specimen immediately after eating breakfast (choice B) may introduce food particles that could contaminate the sample. Collecting it before bed (choice C) may lead to a diluted sample due to daily activities. Collecting the specimen after having a drink of water (choice D) can also result in a diluted sample, impacting the accuracy of the test results.

2. The healthcare provider is caring for a client with dehydration. Which assessment finding indicates that the client is responding to treatment?

• A. Dry mucous membranes
• B. Increased urine output
• C. Decreased heart rate
• D. Elevated blood pressure

Correct answer: B

Rationale: Increased urine output is the correct assessment finding that indicates the client is responding to treatment for dehydration. When a client is dehydrated, their urine output tends to decrease as the body tries to conserve fluids. Therefore, an increase in urine output suggests that the client's hydration status is improving. Dry mucous membranes (Choice A) are a sign of dehydration and would not indicate a positive response to treatment. Decreased heart rate (Choice C) and elevated blood pressure (Choice D) are not specific indicators of hydration status in a client with dehydration.

3. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

• A. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
• B. Pinch the skin on the back of the hand and observe for elasticity
• C. Assess the skin turgor on the abdomen by pinching the skin
• D. Check the skin turgor by pressing on the forearm and observing the rebound

Correct answer: A

Rationale: To assess skin turgor, the nurse should grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. This method is preferred for older adults and in cases of significant fluid imbalance. Option B is incorrect as assessing skin turgor on the back of the hand is not the standard assessment site for skin turgor. Option C is incorrect as the abdomen is not the typical area for assessing skin turgor; the chest under the clavicle is a more accurate site. Option D is incorrect as pressing on the forearm is not the appropriate site for evaluating skin turgor; the chest under the clavicle is the recommended location for this assessment.

4. To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is a nurse manager functioning?

• A. Case manager - responsible for overseeing a case load of clients but does not provide direct client care
• B. Client educator
• C. Client advocate
• D. Supervisor

Correct answer: D

Rationale: The correct answer is D: Supervisor. In this scenario, the nurse manager is acting as a supervisor to oversee and ensure the newly licensed nurse performs the straight catheterization correctly, following protocols, and maintaining client safety. A supervisor role involves monitoring and guiding staff in their duties to ensure quality care. Choices A, B, and C are incorrect. A case manager typically manages a case load of clients but does not provide direct care like in this situation. Client educator and client advocate roles do not directly relate to supervising or overseeing a procedure being performed by another nurse.

5. A client admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client’s temperature is 39.2°C (102.6°F), her abdomen is soft without tenderness, and her menses are overdue by 2 days. To which observation should the nurse give priority attention?

• A. The client’s temperature
• B. The client’s menses are overdue
• C. The client’s crying
• D. The client’s soft abdomen

Correct answer: B

Rationale: The correct answer is B. An overdue menses might indicate a potential cause of abdominal pain, especially in the context of recent emotional stress. While the client's temperature, crying, and soft abdomen are important observations, the priority should be given to the overdue menses as it could provide crucial information related to the abdominal pain and the client's overall health status. The emotional distress may have a secondary impact on the physical symptoms, making the menstrual status a critical observation to address first.

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