Nursing Elites

1. A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

• A. Wipe the area around the needleless port with sterile water
• B. Insert the syringe into the needleless port at a 60-degree angle
• C. Withdraw 3 to 5 ml of urine from the port
• D. Don sterile gloves

Correct answer: C

Rationale: The correct action for the nurse to take is to withdraw 3 to 5 ml of urine from the port for an accurate culture and sensitivity test. Wiping the area around the needleless port with sterile water (Choice A) is not necessary when obtaining a urine specimen. Inserting the syringe into the needleless port at a 60-degree angle (Choice B) is incorrect as it does not align with the correct procedure for obtaining a urine specimen. Donning sterile gloves (Choice D) is a good practice but not the immediate action required for obtaining a urine specimen.

2. A healthcare provider is assessing a client who has carpal tunnel syndrome. The provider should expect which of the following findings?

• A. Positive Chvostek's sign
• B. Cool extremities
• C. Positive Phalen's sign
• D. Decreased radial pulse

Correct answer: C

Rationale: Phalen's sign is often positive in clients with carpal tunnel syndrome due to nerve compression. Chvostek's sign (Choice A) is related to hypocalcemia, cool extremities (Choice B) are not typically associated with carpal tunnel syndrome, and decreased radial pulse (Choice D) is not a common finding in carpal tunnel syndrome.

3. Which of the following is a correct method of safely using a sterile dressing?

• A. Reuse a dressing that appears clean.
• B. Discard a dressing after 24 hours of use.
• C. Change a dressing only if there is visible drainage.
• D. Change a dressing every 4 hours regardless of condition.

Correct answer: B

Rationale: The correct method of safely using a sterile dressing is to discard it after 24 hours of use. This is important to prevent contamination and promote proper wound healing. Choice A is incorrect because reusing a dressing, even if it appears clean, can introduce contaminants. Choice C is incorrect as dressing changes should not be based solely on visible drainage; they should be done within the recommended time frame. Choice D is incorrect because changing a dressing every 4 hours, regardless of its condition, can lead to unnecessary wastage and disturbance to the wound healing process.

4. A patient has difficulty ambulating after surgery. Which action should the nurse take first?

• A. Encourage deep breathing exercises.
• B. Assist the patient in ambulating a short distance.
• C. Call for assistance with ambulation.
• D. Assess the patient's pain level before ambulation.

Correct answer: C

Rationale: The correct first action for the nurse to take when a patient has difficulty ambulating after surgery is to call for assistance with ambulation. This is essential to ensure the safety of the patient and prevent any potential falls or injuries. Encouraging deep breathing exercises (Choice A) may be beneficial but should not be the first priority when the patient is having difficulty walking. Assisting the patient in ambulating a short distance (Choice B) may put both the patient and the nurse at risk if the patient is struggling. Assessing the patient's pain level before ambulation (Choice D) is important but should come after ensuring that the patient can safely ambulate with assistance.

5. A client with a history of falls is under the care of a nurse. Which intervention is most important to implement?

• A. Increase the frequency of bed checks.
• B. Use bed alarms to prevent falls.
• C. Keep the room well lit during the day.
• D. Encourage the client to use a walker for mobility.

Correct answer: B

Rationale: Using bed alarms to prevent falls is the most important intervention to implement for a client with a history of falls. Bed alarms can provide timely alerts to the healthcare team, allowing for quick assistance to prevent falls. Increasing the frequency of bed checks may not necessarily prevent falls as effectively as direct intervention with bed alarms. Keeping the room well lit is important for general safety but may not address the immediate risk of falls. Encouraging the client to use a walker for mobility is beneficial but may not be as crucial as implementing bed alarms to prevent falls in this scenario.

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