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. A nurse is caring for a client who had a total thyroidectomy and has a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?

• A. Shortened QT intervals
• B. Hypoactive deep tendon reflexes
• C. Tingling of the extremities
• D. Constipation

Correct answer: C

Rationale: The correct answer is C: Tingling of the extremities. Tingling is a common symptom of hypocalcemia, which is expected with low calcium levels after a thyroidectomy. Option A, shortened QT intervals, is associated with hypercalcemia rather than hypocalcemia. Option B, hypoactive deep tendon reflexes, is not typically related to hypocalcemia. Option D, constipation, is not a common finding associated with low calcium levels.

3. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?

• A. Lock beds and wheelchairs when not in use
• B. Administer a sedative at bedtime
• C. Provide information about home safety checks
• D. Teach balance and strengthening exercises

Correct answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

4. A patient has just undergone a tracheostomy. What is the nurse's priority intervention?

• A. Suction the tracheostomy to maintain a patent airway.
• B. Administer pain medication as prescribed.
• C. Change the tracheostomy dressing every 4 hours.
• D. Monitor the patient's oxygen saturation closely.

Correct answer: A

Rationale: The correct answer is to suction the tracheostomy to maintain a patent airway. After a tracheostomy, the priority intervention is to ensure a clear airway to prevent respiratory distress. Administering pain medication, changing the tracheostomy dressing, and monitoring oxygen saturation are important but are secondary to maintaining a patent airway in a patient who has just undergone a tracheostomy.

5. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which of the following is a priority nursing intervention?

• A. Administer a dextrose 50% IV bolus
• B. Provide 8 oz of orange juice
• C. Administer regular insulin IV infusion
• D. Give oral metformin

Correct answer: C

Rationale: The correct answer is C: Administer regular insulin IV infusion. In diabetic ketoacidosis (DKA), the priority intervention is to rapidly decrease blood glucose levels. Administering regular insulin via IV infusion helps in lowering blood glucose effectively and quickly. Choice A, administering a dextrose 50% IV bolus, is incorrect because it would further increase blood sugar levels. Choice B, providing orange juice, is not appropriate for treating DKA as it contains sugar that will elevate blood glucose levels. Choice D, giving oral metformin, is not suitable for immediate blood glucose reduction as it acts over time and is not the first-line treatment for DKA.

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