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. When providing oral care to an unconscious patient, what action should the nurse take to protect the patient from injury?

• A. Moisten the mouth using lemon-glycerin sponges.
• B. Hold the patient's mouth open with gloved fingers.
• C. Use foam swabs to help remove plaque.
• D. Suction the oral cavity.

Correct answer: D

Rationale: When caring for an unconscious patient, it is crucial to prevent choking and aspiration. Suctioning the oral cavity helps in removing secretions and preventing potential harm. Moisten the mouth using lemon-glycerin sponges may not effectively clear secretions. Holding the patient's mouth open with gloved fingers can cause discomfort and potential harm. Using foam swabs to remove plaque may not address the immediate risk of aspiration.

3. The healthcare provider is planning care for a 14-year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?

• A. Administer antibiotic therapy for 10 days
• B. Teach the client isometric exercises for legs
• C. Assess movement and sensation of extremities
• D. Assist the client to stand up at the bedside within the first 24 hours

Correct answer: C

Rationale: Assessing movement and sensation of extremities is the priority after scoliosis corrective surgery as it helps in early detection of any neurological deficits that may have occurred during the procedure. This assessment is essential for prompt intervention if any issues are identified. Administering antibiotics, teaching exercises, and assisting the client to stand up are important aspects of care but assessing neurological status takes precedence to ensure the client's safety and recovery.

4. 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.

5. A healthcare professional is providing care to a client who has a tracheostomy. Which of the following actions should the professional take to prevent complications?

• A. Clean around the stoma with povidone-iodine.
• B. Maintain sterile technique when performing tracheostomy care.
• C. Use clean technique when suctioning the tracheostomy.
• D. Change tracheostomy ties weekly.

Correct answer: B

Rationale: Maintaining sterile technique when performing tracheostomy care is essential in preventing infections and complications. Option A is incorrect because povidone-iodine may be too harsh for cleaning around the stoma and can lead to skin irritation. Option C is incorrect because suctioning a tracheostomy should be done using sterile technique to minimize the risk of introducing pathogens. Option D is incorrect as tracheostomy ties need to be changed more frequently, usually every 1-2 days, to prevent skin breakdown and infection.

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