Nursing Elites

1. A nurse is providing care to a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent catheter-associated urinary tract infections (CAUTIs)?

• A. Irrigate the catheter with sterile water daily.
• B. Empty the catheter bag every 8 hours.
• C. Clean the perineal area with antiseptic solution daily.
• D. Secure the catheter to the client's thigh.

Correct answer: D

Rationale: Securing the catheter to the client's thigh is the correct action to prevent CAUTIs. By securing the catheter, movement is minimized, reducing the risk of introducing bacteria into the urinary tract. Choice A is incorrect because routine irrigation of the catheter is not recommended as it can increase the risk of infection. Choice B is incorrect as emptying the catheter bag every 8 hours is important for proper drainage but does not directly prevent CAUTIs. Choice C is incorrect because cleaning the perineal area with antiseptic solution does not address the main source of CAUTIs related to catheter care.

2. A home health nurse is teaching a new caregiver how to care for a client who has had a tracheostomy for 1 year. Which of the following instructions should the nurse include?

• A. Use tracheostomy covers when going outdoors.
• B. Maintain sterile technique when performing tracheostomy care.
• C. Do not remove the outer cannula for routine cleaning.
• D. Clean around the stoma with normal saline.

Correct answer: A

Rationale: The correct answer is to use tracheostomy covers when going outdoors. This instruction is important as it helps protect the airway from dust and other particles, reducing the risk of infection or irritation. Choice B is incorrect because maintaining sterile technique is crucial during tracheostomy care to prevent infections, but it is not the most pertinent instruction in this scenario. Choice C is incorrect as removing the outer cannula is not a routine cleaning procedure and should only be done by healthcare professionals when necessary. Choice D is incorrect because cleaning around the stoma with normal saline is not recommended as it can cause irritation to the skin and stoma site.

3. During an abdominal assessment for an adult client, what is the correct sequence of steps?

• A. Inspect, Auscultate, Percuss, Palpate
• B. Palpate, Percuss, Inspect, Auscultate
• C. Auscultate, Inspect, Percuss, Palpate
• D. Percuss, Palpate, Inspect, Auscultate

Correct answer: A

Rationale: The correct sequence for an abdominal assessment in an adult client is to first Inspect the abdomen for any visible abnormalities, then Auscultate to listen for bowel sounds, followed by Percussion to assess for organ size and presence of fluid or masses, and finally Palpation to feel for tenderness, masses, or organ enlargement. Choice A, 'Inspect, Auscultate, Percuss, Palpate,' is the correct sequence for an abdominal assessment. Choices B, C, and D are incorrect because they do not follow the recommended sequence of assessment. Palpation should be the last step as it can potentially alter bowel sounds and percussion findings if done before. This deviation can lead to missing important findings or inaccurate assessment results.

4. While assisting a client with a meal, the client suddenly grabs at their neck with both hands and appears frightened. The appropriate nursing action is to:

• A. Ask the client if they are choking
• B. Perform abdominal thrusts
• C. Call for emergency help
• D. Check the client’s airway

Correct answer: A

Rationale: The correct action when a client suddenly grabs at their neck and appears frightened is to ask if they are choking. This allows the nurse to gather more information from the client directly. Performing abdominal thrusts (choice B) should only be done if the client is unable to speak, cough, or breathe. Calling for emergency help (choice C) should be done after assessing the situation and confirming choking. Checking the client's airway (choice D) is important but should come after confirming that the client is choking.

5. A child is injured on the school playground and appears to have a fractured leg. What action should the school nurse take first?

• A. Call for emergency transport to the hospital
• B. Immobilize the limb and joints above and below the injury
• C. Assess the child and the extent of the injury
• D. Apply cold compresses to the injured area

Correct answer: C

Rationale: The correct first action for the school nurse to take when a child is injured and appears to have a fractured leg is to assess the child and the extent of the injury. This initial assessment is crucial to determine the severity of the injury before proceeding with further interventions. Option A, calling for emergency transport, should only be done after assessing the extent of the injury. Option B, immobilizing the limb and joints, is important but should come after the initial assessment. Option D, applying cold compresses, is not recommended for suspected fractures as it can exacerbate swelling and pain.

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