Nursing Elites

1. To obtain a sterile urine specimen from a client with a Foley catheter, the nurse begins by applying a clamp to the drainage tubing distal to the injection port. What does the nurse do next?

• A. Clamp another section of the tube to create a fixed sample section for retrieval.
• B. Insert a syringe into the injection port and aspirate the quantity of urine required.
• C. Clean the injection port cap of the drainage tubing with povidone-iodine solution.
• D. Withdraw 10 mL of urine and discard it; then withdraw 10 mL more for the sample.

Correct answer: C

Rationale: After clamping the drainage tubing, the next step in obtaining a sterile urine specimen from a client with a Foley catheter is to clean the injection port cap of the drainage tubing with povidone-iodine solution. This cleaning step helps prevent contamination of the urine sample. Clamping another section of the tube isn't necessary and may not be a standard practice. Inserting a syringe into the injection port to aspirate urine isn't the correct step at this point. Withdrawing 10 mL of urine and discarding it before collecting the sample isn't appropriate and may lead to an inaccurate sample.

2. The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client? (Select one that doesn't apply.)

• A. Use sterile gloves and gowns whenever the nursing staff is in contact with the client.
• B. Keep a blood pressure cuff, thermometer, and stethoscope in the client's room for his or her use only
• C. Request that the family take home the fresh flowers that are at the client's bedside
• D. Assist the client with meticulous oral care after meals and at bedtime.

Correct answer: A

Rationale:

3. A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children."? How does the nurse respond?

• A. "Caring for your children is a priority. You may not want to ask for help, but you have to."?
• B. "Our community has resources that may help you with some household tasks so you have energy to care for your children."?
• C. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?"?
• D. "Give me more information about what worries you, so we can see if we can do something to make adjustments."?

Correct answer: D

Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.

4. How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?

• A. Poor left-sided motor control
• B. Paralysis or contractures on the right side
• C. Limited visual perception of the left fields
• D. Unawareness of the existence of her left side

Correct answer: D

Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.

5. A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy?

• A. Tenting of skin on the back of the hand
• B. Increased urine osmolarity
• C. Weight loss of 10 pounds
• D. Pulse rate of 115 beats/min

Correct answer: D

Rationale: The correct answer is the pulse rate of 115 beats/min. A rapid pulse rate is a sign of compensatory mechanisms in response to dehydration, indicating that the body is trying to deliver oxygen more efficiently. Oxygen therapy may be needed to support the increased oxygen demand. Tenting of skin on the back of the hand is a classic sign of dehydration due to decreased skin turgor. Increased urine osmolarity and weight loss are also indicators of dehydration, but they do not directly suggest a need for oxygen therapy.

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