Nursing Elites

1. The client is being instructed on how to collect a clean catch urine specimen. Which sequence is appropriate for teaching?

• A. Void a little, clean the meatus, then collect specimen
• B. Clean the meatus, begin voiding, then catch urine stream
• C. Clean the meatus, then urinate into container
• D. Void continuously and catch some of the urine

Correct answer: B

Rationale: The correct sequence for obtaining a clean catch urine specimen involves first cleaning the meatus to prevent contamination, then initiating voiding to catch the midstream urine. This method ensures that the sample is as uncontaminated as possible, making choice B the correct sequence. Option A is incorrect as cleaning the meatus should be done before voiding. Option C is incorrect as it does not involve catching a midstream urine sample. Option D is incorrect as it suggests catching urine throughout the entire voiding process, which may lead to contamination.

2. A client who is postoperative is being taught how to use a flow-oriented incentive spirometer. Which of the following instructions should be included by the nurse?

• A. Cough deeply after each use.
• B. Take a deep breath and hold for 10 seconds.
• C. Breathe in slowly and deeply to raise the ball or piston.
• D. Exhale forcefully before using the spirometer.

Correct answer: C

Rationale: The correct technique for using a flow-oriented incentive spirometer involves breathing in slowly and deeply to raise the ball or piston. This action helps to expand the lungs and improve lung function. Option A is incorrect as coughing deeply after each use is not part of using the spirometer. Option B is incorrect as holding the breath for 10 seconds is not the correct instruction for using the spirometer. Option D is incorrect as exhaling forcefully before using the spirometer is not the appropriate step in using this device.

3. The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?

• A. Maintain a narrow base of support.
• B. Dangle the patient at the bedside.
• C. Encourage isometric exercises.
• D. Suggest a high-calcium diet.

Correct answer: B

Rationale: The correct action the nurse should take first when a patient needs to be mobilized after being in bed for several days is to dangle the patient at the bedside. Dangling at the bedside is the initial step to assess the patient's tolerance to sitting up and moving. It helps prevent orthostatic hypotension and allows the nurse to evaluate the patient's response to upright positioning before attempting further ambulation. Maintaining a narrow base of support (Choice A) is related to assisting with ambulation but is not the first step. Encouraging isometric exercises (Choice C) and suggesting a high-calcium diet (Choice D) are not immediate actions needed to initiate mobilization in this scenario.

4. While ambulating an unsteady client who begins to fall, which of the following actions should the nurse take?

• A. Allow the client to slide down their outstretched leg.
• B. Place their arms around the client to prevent the fall.
• C. Remain upright as the client falls toward them.
• D. Move quickly to a position in front of the client.

Correct answer: A

Rationale: When a client is falling, allowing them to slide down your leg can help control the descent and prevent injury. This technique ensures a more controlled fall compared to attempting to catch or stop the client abruptly, which could lead to both the client and the nurse getting injured. Placing arms around the client may not provide enough support or control during the fall. Remaining upright or moving quickly in front of the client might not be practical or safe in this scenario.

5. A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?

• A. “I will determine the most important client problems that we should address.”
• B. “I will review the past medical history on the client’s record to gather more information.”
• C. “I will carry out the new prescriptions from the provider.”
• D. “I will ask the client if their nausea has resolved.”

Correct answer: A

Rationale: In the nursing process, the planning step involves determining priorities and goals based on the identified problems. Choice A is correct as it reflects the nurse's role in identifying the most important client problems to address, which aligns with the planning phase. Choices B, C, and D are incorrect. Choice B involves data collection, which is a part of the assessment phase, not planning. Choice C pertains to the implementation of care, which occurs after the planning phase. Choice D involves evaluation of a specific intervention, not planning.

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