Nursing Elites

1. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:

• A. Cleanse the entry port prior to withdrawing urine.
• B. Use a sterile syringe to collect urine from the collection bag.
• C. Obtain the specimen from the drainage tubing.
• D. Replace the catheter before obtaining the specimen.

Correct answer: A

Rationale: The correct procedure when obtaining a urine specimen from an indwelling catheter for culture and sensitivity is to cleanse the entry port before withdrawing urine. This step helps reduce the risk of contamination and ensures the accuracy of the results. Option B is incorrect because using a sterile syringe to collect urine from the collection bag is not the recommended method for obtaining a catheter specimen. Option C is incorrect as obtaining the specimen from the drainage tubing is not the appropriate technique for collecting a urine sample from an indwelling catheter. Option D is incorrect because replacing the catheter before obtaining the specimen is not necessary and may introduce unnecessary complications.

2. During preoperative education, a nurse should assess a client's readiness to learn before a mastectomy. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

• A. “I don’t want my spouse to see my incision.”
• B. “Will you give me pain medicine after the surgery?”
• C. “Can you tell me about how long the surgery will take?”
• D. “My roommate listens to everything I say.”

Correct answer: C

Rationale: The correct answer is C. Asking about the duration of the surgery indicates readiness to learn about the procedure. This question shows that the client is actively seeking information about the surgical process, demonstrating readiness to learn. Choices A, B, and D reflect concerns, specific requests, or statements unrelated to the learning process. They do not directly indicate readiness to absorb information about the upcoming mastectomy.

3. What should be done when caring for a client who died?

• A. Obtain orders, Remove tubes, Wash client, Ask family, Place tags.
• B. Wash client, Obtain orders, Place tags, Remove tubes, Ask family.
• C. Remove tubes, Obtain orders, Ask family, Place tags, Wash client.
• D. Ask family, Place tags, Wash client, Remove tubes, Obtain orders.

Correct answer: A

Rationale: When caring for a deceased client, the correct sequence of actions involves first obtaining any necessary orders, then removing tubes, washing the client, asking the family for specific requests, and finally placing identification tags. This order ensures proper care and respect for the deceased individual. Option A presents the correct order of actions. Choice B is incorrect because washing the client should be done after removing tubes. Choice C is incorrect as it does not follow the correct order of actions. Choice D is incorrect because asking the family should be done after caring for the client's body, not before.

4. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to

• A. Change whichever item is incorrect to the correct information
• B. Use the bracelet and admission form until a replacement is supplied
• C. Notify the admissions office and wait to apply the bracelet
• D. Make a corrected identification bracelet for the client

Correct answer: C

Rationale: The nurse should notify the admissions office and wait to apply the bracelet. By doing so, the nurse ensures patient safety and accuracy in identification. Changing the incorrect item (Choice A) could lead to errors and confusion in the patient's identification. Using the mismatched items until a replacement is supplied (Choice B) compromises patient safety and could result in errors during care delivery. Making a corrected identification bracelet without verifying the correct information (Choice D) could introduce further inaccuracies and risks in patient identification.

5. A healthcare professional is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the healthcare professional take?

• A. Administer the medication with the needle at a 45-degree angle.
• B. Administer the medication with the needle at a 90-degree angle.
• C. Inject the medication into the muscle.
• D. Pinch the skin before injecting.

Correct answer: B

Rationale: Enoxaparin is a medication that is administered subcutaneously, which means it should be injected into the fatty tissue layer beneath the skin. Administering enoxaparin at a 90-degree angle ensures proper absorption and reduces the risk of injecting the medication into muscle tissue, which could affect its effectiveness. Injecting the medication at a 45-degree angle may lead to improper absorption as it may not reach the subcutaneous tissue adequately. Injecting the medication into the muscle instead of subcutaneously can alter the absorption rate and therapeutic effects. Pinching the skin before injecting is not necessary for administering enoxaparin subcutaneously and may cause unnecessary discomfort to the client.

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