Nursing Elites

1. When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?

• A. Position the client supine for a few minutes
• B. Assist the client to stand at the bedside
• C. Apply the blood pressure cuff securely
• D. Record the client’s pulse rate and rhythm

Correct answer: A

Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.

2. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift?

• A. Assess the client for confusion and reteach the procedure
• B. Check the urine for color and texture
• C. Empty the urinal contents into the 24-hour collection container
• D. Discard the contents of the urinal

Correct answer: C

Rationale: To ensure accurate creatinine clearance results, it is crucial to collect all urine within the 24-hour period. The process should begin with discarding the first specimen and then collecting all subsequent urine in the designated 24-hour collection container. This ensures that the sample is complete and accurate for the creatinine clearance calculation.

3. You are assigned to teach a student how to suction an adult patient with a tracheostomy. Which of the following actions by the student would be incorrect?

• A. Pre-oxygenating the patient with a Resuscibag at 100% O2 several times before suctioning.
• B. Maintaining wall suction pressure at 110-150 mmHg.
• C. Not suctioning for greater than 10-15 seconds at a time.
• D. Applying gentle intermittent pressure and rotating the catheter during the insertion phase of suctioning.

Correct answer: D

Rationale: The incorrect action by the student is applying gentle intermittent pressure and rotating the catheter during the insertion phase of suctioning. This technique can cause trauma to the tracheal walls, increasing the risk of injury to the patient. It is essential to perform suctioning gently and without rotation to prevent complications in patients with a tracheostomy. Pre-oxygenating the patient, maintaining appropriate suction pressure, and limiting suctioning time are all correct actions when suctioning a patient with a tracheostomy.

4. During a sterile procedure at a client's bedside, a healthcare provider contaminates a sterile glove and the sterile field. What is the best action for the nurse to implement?

• A. Report the incident to the supervisor for aseptic technique violation.
• B. Allow the completion of the procedure.
• C. Inquire about the contamination of the glove and sterile field.
• D. Identify the breach in surgical asepsis and provide a new set of sterile supplies.

Correct answer: D

Rationale: In the scenario where a healthcare provider contaminates a sterile glove and the sterile field during a procedure, it is crucial to identify any breach in surgical asepsis. Any potential contamination should be considered compromised, and the nurse must act promptly to maintain sterility by providing a fresh set of sterile supplies for the procedure to continue safely.

5. A client with frequent urinary tract infections (UTIs) asks the nurse about drinking juice daily to prevent future UTIs. Which response is best for the nurse to provide?

• A. Orange juice has vitamin C, which deters bacterial growth.
• B. Apple juice is the most useful in acidifying the urine.
• C. Cranberry juice stops pathogens' adherence to the bladder.
• D. Grapefruit juice increases the absorption of most antibiotics.

Correct answer: C

Rationale: Cranberry juice is known for its ability to prevent urinary tract infections by reducing the adherence of Escherichia coli bacteria to the cells within the bladder. This property helps in maintaining urinary tract health and preventing recurrent UTIs. Choices A, B, and D are incorrect because while vitamin C in orange juice may have some benefits, it is not specifically known for deterring bacterial growth in the urinary tract. Apple juice does not significantly impact urine acidity, and grapefruit juice does not enhance antibiotic absorption, making them less effective choices for preventing UTIs compared to cranberry juice.

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