Nursing Elites

1. A client has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

• A. Ensure the catheter tubing is free of kinks.
• B. Clean the perineal area with antiseptic solution daily.
• C. Irrigate the catheter with normal saline every shift.
• D. Secure the catheter to the client's leg.

Correct answer: B

Rationale: Cleaning the perineal area with antiseptic solution daily is essential to prevent infection when caring for a client with an indwelling urinary catheter. This practice helps reduce the risk of introducing pathogens into the urinary tract. Ensuring the catheter tubing is free of kinks (Choice A) is important for maintaining proper urine flow but is not directly related to preventing infection. Irrigating the catheter with normal saline every shift (Choice C) is not a routine practice and can increase the risk of introducing pathogens. Securing the catheter to the client's leg (Choice D) is important for stability but does not directly prevent infection.

2. What action should the nurse take if she observes an unlicensed assistive personnel (UAP) soaking a client's foot in a basin of warm water placed on the bed during a total bed bath for a confused and lethargic client?

• A. Remove the basin of water from the client's bed immediately
• B. Remind the UAP to dry between the client's toes completely
• C. Advise the UAP that this procedure may damage the skin
• D. Add skin cream to the basin of water while the foot is soaking

Correct answer: A

Rationale: The correct action for the nurse to take is to remove the basin of water from the client's bed immediately. Soaking a client's foot in a basin of water placed on the bed can lead to spills, create infection risks, and is not a safe practice. It is essential to prioritize the safety and well-being of the client by ensuring a safe environment during care procedures. Choices B, C, and D are incorrect as they do not address the immediate risk associated with the situation. Reminding the UAP to dry between the client's toes, advising about potential skin damage, or adding skin cream do not mitigate the immediate hazards of having a basin of water on the bed.

3. How should the nurse transcribe the dosage of this medication on the client's medical record?

• A. 0.3 mg
• B. 0.3 mg
• C. 0.30 mg
• D. 3/10 mg

Correct answer: B

Rationale: The correct way to transcribe the dosage of three tenths of a milligram of levothyroxine IV STAT is 0.3 mg. When expressing decimals less than 1, there should be a leading zero before the decimal point. Choice A is incorrect (.3 mg) because it lacks the leading zero. Choice C (0.30 mg) is incorrect as it includes a trailing zero after the decimal point, which is unnecessary. Choice D (3/10 mg) is incorrect as it presents the dosage as a fraction, which is not the standard format for transcribing medication dosages. Therefore, B (0.3 mg) is the most appropriate and accurate way to document this prescription on the client's medical record.

4. When preparing to apply dressing to a stage 2 pressure injury, which type of dressing should the nurse use?

• A. Hydrocolloid
• B. Gauze
• C. Transparent film
• D. Alginate

Correct answer: A

Rationale: The correct answer is A: Hydrocolloid. Hydrocolloid dressings are recommended for stage 2 pressure injuries as they help maintain a moist wound environment, which supports the healing process. Gauze (choice B) is not ideal for stage 2 pressure injuries as it can stick to the wound bed and disrupt the healing process. Transparent film dressings (choice C) are more suitable for superficial wounds or as a secondary dressing. Alginate dressings (choice D) are typically used for wounds with heavy exudate, which is not typically seen in stage 2 pressure injuries.

5. A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?

• A. Members of the same religion may have varying feelings about their religion.
• B. A shared religion background does not guarantee identical beliefs.
• C. The same religious beliefs can influence individuals differently.
• D. Discussing differences and commonalities in beliefs may not always be relevant.

Correct answer: C

Rationale: The correct answer is C. Religious beliefs can vary widely even among individuals of the same faith. It is essential for the nurse to recognize that the impact and interpretation of religious beliefs can differ from person to person. Choice A is incorrect as individuals within the same religion can have diverse feelings and interpretations. Choice B is incorrect because a shared religious background does not necessarily mean that individuals hold the same beliefs. Choice D is not the best course of action as discussing differences and commonalities in beliefs may not always be necessary or appropriate for providing care.

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