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 client has a do-not-resuscitate (DNR) order. The family asks the nurse to ignore the DNR if the client codes. What is the nurse's responsibility?

• A. Follow the family's wishes
• B. Explain that the DNR must be honored
• C. Ignore the DNR and proceed with CPR
• D. Perform CPR if the client codes

Correct answer: B

Rationale: The correct answer is B: 'Explain that the DNR must be honored.' The nurse's responsibility is to follow the DNR order, as it is a legal and ethical obligation. Choice A is incorrect because following the family's wishes would go against the established DNR order. Choice C is incorrect as ignoring the DNR order is not appropriate. Choice D is also incorrect as performing CPR would be contrary to the client's expressed wishes in the DNR order.

3. A client requires suctioning every 2 hours. To whom should the nurse delegate this task?

• A. Delegate to a licensed practical nurse (LPN)
• B. Delegate to a registered nurse (RN)
• C. Delegate to a nursing assistant (NA)
• D. Perform the task independently

Correct answer: A

Rationale: The correct answer is to delegate the task to a licensed practical nurse (LPN). LPNs can typically perform suctioning, but it is essential to consider the state's practice guidelines and hospital policy. Option B, delegating to a registered nurse (RN), is not necessary for this task as LPNs are usually competent to handle suctioning. Option C, delegating to a nursing assistant (NA), may not be appropriate as suctioning may require a higher level of training and expertise. Option D, performing the task independently, is not the best choice as delegation is a key aspect of nursing practice to ensure tasks are appropriately assigned based on competency levels.

4. A healthcare provider is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

• A. Bladder scan shows 525 mL
• B. Absent urinary output for 1 hour
• C. Cloudy urine
• D. Bloody urine

Correct answer: A

Rationale: The correct answer is A. A large bladder scan result (525 mL) suggests catheter blockage and may require irrigation to resolve. Choice B (absent urinary output for 1 hour) could indicate a different issue such as urinary retention but does not specifically indicate the need for catheter irrigation. Choices C (cloudy urine) and D (bloody urine) may suggest infection or other urinary issues, but they do not directly indicate the need for catheter irrigation.

5. Which of the following is a primary focus of tertiary prevention in mental health?

• A. Identifying early signs of mental illness
• B. Preventing the occurrence of mental health problems
• C. Rehabilitation and prevention of further deterioration
• D. Providing a safe environment to prevent harm

Correct answer: C

Rationale: The correct answer is C: Rehabilitation and prevention of further deterioration. Tertiary prevention in mental health aims to provide interventions and support to individuals who already have a mental illness to prevent further deterioration and promote recovery. Choice A, identifying early signs of mental illness, is more aligned with primary prevention which focuses on preventing the onset of mental health problems. Choice B, preventing the occurrence of mental health problems, pertains to secondary prevention which involves early detection and intervention to prevent the progression of mental health issues. Choice D, providing a safe environment to prevent harm, is important but it is not the primary focus of tertiary prevention which is more centered on rehabilitation and improving the quality of life for individuals with existing mental health conditions.

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