Nursing Elites

1. A healthcare professional is preparing to insert an indwelling urinary catheter. What is the most important action to prevent infection?

• A. Use sterile gloves during the procedure.
• B. Clean the catheter insertion site with alcohol.
• C. Insert the catheter as quickly as possible.
• D. Use a smaller catheter size to minimize trauma.

Correct answer: A

Rationale: Using sterile gloves during catheter insertion is crucial to prevent infection. Sterile gloves help maintain asepsis during the procedure, reducing the risk of introducing microorganisms into the urinary tract. Cleaning the insertion site with alcohol, as mentioned in choice B, is important but not as critical as using sterile gloves. Choice C, inserting the catheter as quickly as possible, is not recommended as it can lead to errors and increase the risk of contamination. Choice D, using a smaller catheter size to minimize trauma, is not directly related to preventing infection but rather focuses on patient comfort and reducing tissue damage.

2. After unsuccessful alternatives, a patient requires restraints. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care?

• A. The health care provider writes the type and location of the restraint.
• B. The health care provider renews orders for restraints every 24 hours.
• C. The health care provider performs a face-to-face assessment prior to the order.
• D. The health care provider orders restraints PRN (as needed).

Correct answer: A

Rationale: In the context of restraining a patient, it is crucial for the health care provider to specify the type and location of the restraint in the order to ensure the safety and well-being of the patient. This information helps guide the nursing staff in the safe application of restraints. Renewing orders every 24 hours ensures that the need for restraints is continually assessed, promoting patient safety. Performing a face-to-face assessment before ordering restraints allows for a thorough evaluation of the patient's condition and the necessity of using restraints. Ordering restraints PRN (as needed) is not appropriate for safe care as it lacks specificity and may lead to inconsistent application and monitoring.

3. A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

• A. Glasgow Coma Scale (GCS) score of 12
• B. Edematous bruise on the forehead
• C. Small drops of clear fluid in the left ear
• D. Pupils are 4 mm and reactive to light

Correct answer: C

Rationale: The correct answer is C. Clear fluid draining from the ear may indicate a cerebrospinal fluid (CSF) leak, which is a serious complication following a head injury. Reporting this finding is crucial as it may require immediate medical intervention to prevent further complications. Choices A, B, and D are not as concerning as a CSF leak. A GCS score of 12 is relatively high, indicating a mild level of consciousness alteration. An edematous bruise on the forehead is a common physical finding after a head injury. Pupils that are 4 mm and reactive to light suggest normal pupillary function.

4. The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent?

• A. Hip
• B. Back
• C. Arm
• D. Ankle

Correct answer: B

Rationale: The correct answer is B: Back. Back injuries are most common during lifting and bending tasks, especially in an orthopedic unit. When lifting or repositioning patients, nurses must prioritize proper body mechanics to prevent strain on the back. Choices A, C, and D are less likely to occur as frequently as back injuries in this scenario because of the nature of the tasks involved in orthopedic patient care.

5. Which action by the nurse will help reduce the risk of venous thromboembolism (VTE) in a postoperative patient?

• A. Encourage early ambulation and leg exercises.
• B. Apply compression stockings to the patient's legs.
• C. Administer anticoagulants as prescribed.
• D. Elevate the patient's legs to promote circulation.

Correct answer: A

Rationale: The correct answer is to encourage early ambulation and leg exercises. By promoting early ambulation and leg exercises, blood flow is enhanced, reducing the risk of venous thromboembolism (VTE) in postoperative patients. Choice B, applying compression stockings, helps prevent VTE but is not as effective as early ambulation and exercises. Choice C, administering anticoagulants, is important in VTE prevention but does not directly address improving circulation through physical activity. Choice D, elevating the patient's legs, may be beneficial for circulation in specific cases but is not as effective in preventing VTE as early ambulation and leg exercises.

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