Nursing Elites

1. A client has just returned from surgery with an indwelling urinary catheter in place. What is the most important action for the nurse to take to prevent infection?

• A. Change the catheter every 72 hours.
• B. Ensure the catheter tubing is free of kinks.
• C. Clean the perineal area with antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: B

Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. Kinks in the tubing can lead to urine retention or obstruction, increasing the risk of infection. Changing the catheter every 72 hours is not necessary if there are no signs of infection or other issues. Cleaning the perineal area with antiseptic solution daily is important for hygiene but not the most critical action to prevent infection related to the catheter. Irrigating the catheter with normal saline every shift is not a routine practice and may increase the risk of introducing pathogens into the urinary system.

2. In a disaster at a child day care center, which child would the triage nurse prioritize for treatment last?

• A. An infant with intermittent bulging anterior fontanel between crying episodes
• B. A toddler with severe deep abrasions covering 98% of the body
• C. A preschooler with a lower leg fracture and an upper leg fracture on the other leg
• D. A school-age child with singed eyebrows and hair on the arms

Correct answer: B

Rationale: The toddler with severe deep abrasions covering 98% of the body would be prioritized for treatment last because these extensive injuries may require immediate attention and resources. The other choices present serious conditions but are not as severe or life-threatening as the toddler's injuries. The infant with an intermittent bulging anterior fontanel may have signs of increased intracranial pressure, requiring prompt evaluation. The preschooler's fractures, though serious, can be managed without immediate critical intervention. The school-age child with singed eyebrows and hair may have suffered burns but does not exhibit injuries as severe as the toddler's deep abrasions.

3. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the LPN/LVN implement?

• A. Provide additional coffee on the client's breakfast tray.
• B. Exchange the client's grape juice for cranberry juice.
• C. Bring the client additional fruit at mid-morning.
• D. Encourage additional oral intake of juices and water.

Correct answer: D

Rationale: Encouraging additional oral intake of juices and water is the appropriate intervention in this scenario. Dark amber urine can indicate concentrated urine due to dehydration or other factors. By encouraging more fluids, the LPN/LVN can help dilute the urine, reducing the concentration of pigments causing the dark color. Providing additional coffee (Choice A) would not necessarily increase hydration and could potentially have a diuretic effect. Exchanging grape juice for cranberry juice (Choice B) does not address the core issue of hydration. Bringing additional fruit (Choice C) may provide some fluid, but encouraging specific fluids like juices and water would be more effective in diluting the urine.

4. A healthcare professional is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the healthcare professional plan to initiate?

• A. Contact
• B. Droplet
• C. Airborne
• D. Protective environment

Correct answer: C

Rationale: Tuberculosis is transmitted through airborne particles, so airborne precautions are necessary to prevent the spread of the disease. Airborne precautions (Choice C) involve measures such as negative pressure rooms and N95 respirators to prevent the transmission of infectious agents that remain infectious over long distances when suspended in the air. Contact precautions (Choice A) are used for diseases that spread through direct contact with the patient or their environment. Droplet precautions (Choice B) are for diseases transmitted through respiratory droplets, typically over short distances. Protective environment (Choice D) is used for clients who are immunocompromised to protect them from environmental pathogens, not for diseases like tuberculosis that spread through the air.

5. During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?

• A. Fat
• B. Fluid
• C. Flatus
• D. Hernias

Correct answer: D

Rationale: The correct answer is 'Hernias.' Abdominal distention with a midline protrusion, taut skin, and no involvement of the flanks is characteristic of hernias. Hernias are caused by a weakness in the abdominal wall, allowing organs or tissues to protrude through. Fluid accumulation (ascites) typically presents with a more generalized distention, while fat accumulation may cause more diffuse distension rather than a focal midline protrusion. Flatus, or gas, would not typically present with a visible midline protrusion and taut skin like hernias.

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