Nursing Elites

1. A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

• A. Wipe the area around the needleless port with sterile water
• B. Insert the syringe into the needleless port at a 60-degree angle
• C. Withdraw 3 to 5 ml of urine from the port
• D. Don sterile gloves

Correct answer: C

Rationale: The correct action for the nurse to take is to withdraw 3 to 5 ml of urine from the port for an accurate culture and sensitivity test. Wiping the area around the needleless port with sterile water (Choice A) is not necessary when obtaining a urine specimen. Inserting the syringe into the needleless port at a 60-degree angle (Choice B) is incorrect as it does not align with the correct procedure for obtaining a urine specimen. Donning sterile gloves (Choice D) is a good practice but not the immediate action required for obtaining a urine specimen.

2. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?

• A. Assist the patient with comfort measures.
• B. Keep the patient as mobile as possible.
• C. Encourage the patient to perform ROM.
• D. Encourage the patient to do self-care.

Correct answer: A

Rationale: The correct answer is A: 'Assist the patient with comfort measures.' When a patient is experiencing impaired physical mobility due to pain, the priority action is to provide comfort measures to help manage the pain. By addressing the pain, the patient may then feel more comfortable moving and engaging in mobility exercises. Option B, 'Keep the patient as mobile as possible,' could exacerbate the pain and should not be the initial action. While encouraging range of motion (ROM) exercises (Option C) and self-care (Option D) are important aspects of care, addressing pain and comfort should take precedence in this scenario.

3. The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?

• A. I should call 911 if my grandchild loses consciousness.
• B. Never induce vomiting if my grandchild drinks bleach.
• C. If my grandchild eats a plant, I should provide syrup of ipecac.
• D. The number for poison control is 800-222-1222.

Correct answer: C

Rationale: The correct answer is C. Administering syrup of ipecac is no longer recommended in cases of poisoning. This is because it can lead to complications and is not considered safe. The grandparent should be informed that syrup of ipecac should not be given to a child who has ingested a toxic substance. Choices A, B, and D provide accurate information regarding actions to take in case of poisoning, such as calling 911 if the child loses consciousness, not inducing vomiting if the child drinks bleach, and having the poison control number readily available.

4. A client with asthma is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?

• A. Polyuria
• B. Oral candidiasis
• C. Hypertension
• D. Hypoglycemia

Correct answer: B

Rationale: Correct. Fluticasone, a corticosteroid medication commonly used to manage asthma, can lead to oral candidiasis due to its immunosuppressive effects. This fungal infection can manifest as white patches in the mouth and throat. Monitoring for signs of oral candidiasis is essential to initiate appropriate treatment. Polyuria (excessive urination) is not a common adverse effect of fluticasone. Hypertension and hypoglycemia are also not typically associated with this medication, making them incorrect choices.

5. A nurse manager is teaching a group of staff members about proper body mechanics. Which of the following statements by a staff member indicates an understanding of the teaching?

• A. I should get assistance when lifting more than 35 pounds
• B. I will twist at my waist when moving an object
• C. I should hold objects 1 ft away from my body when I walk
• D. I will roll my shoulders forward to reduce strain on my back

Correct answer: A

Rationale: Choice A is the correct answer because lifting more than 35 pounds without assistance can cause injury, so getting help is crucial for proper body mechanics. Choice B is incorrect as twisting at the waist can lead to back injuries. Choice C is incorrect as holding objects closer to the body, not 1 ft away, is recommended to reduce strain. Choice D is incorrect as rolling shoulders forward can increase strain on the back instead of reducing it.

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