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 is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

• A. Decrease the client's IV fluids
• B. Reposition the client
• C. Administer oxygen by face mask
• D. Document the findings

Correct answer: C

Rationale: Administering oxygen by face mask is the priority intervention when late decelerations are observed in the fetal heart rate. Late decelerations indicate uteroplacental insufficiency, and administering oxygen helps to improve fetal oxygenation. Repositioning the client may also be necessary to relieve pressure on the umbilical cord, but providing oxygen takes precedence to enhance fetal oxygenation. Decreasing IV fluids may not directly address the underlying issue leading to late decelerations. Documenting the findings is important but should not be the first action taken when managing late decelerations.

3. A patient with a left arm fracture reports severe pain unrelieved by medication. What should the nurse assess for?

• A. Check for compartment syndrome
• B. Increase the pain medication
• C. Prepare the patient for surgery immediately
• D. Administer a sedative to calm the patient

Correct answer: A

Rationale: Correct answer: When a patient with a left arm fracture reports severe pain unrelieved by medication, the nurse should assess for compartment syndrome. Compartment syndrome is a condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. It is a surgical emergency that requires immediate intervention. Choice B is incorrect because simply increasing pain medication without identifying the cause of the unrelieved pain may mask symptoms of a serious issue like compartment syndrome. Choice C is incorrect as surgery would only be necessary if compartment syndrome is confirmed. Choice D is incorrect as administering a sedative does not address the underlying issue of unrelieved pain and may delay appropriate treatment.

4. What are the nursing interventions for a patient with acute kidney injury (AKI)?

• A. Preparing the patient for dialysis if necessary
• B. Providing dietary modifications to reduce potassium
• C. Monitoring urine output and electrolytes
• D. Administering fluids and monitoring blood pressure

Correct answer: A

Rationale: The correct nursing intervention for a patient with acute kidney injury (AKI) includes preparing the patient for dialysis if necessary. While choices B, C, and D are also important aspects of managing AKI, the critical intervention in severe cases is to prepare the patient for dialysis to support kidney function. Providing dietary modifications to reduce potassium, monitoring urine output and electrolytes, and administering fluids are essential components of the overall care plan for AKI patients, but in cases where the condition is severe or if conservative management fails, dialysis may be required to support the patient's kidney function and prevent further complications.

5. A female client with anxiety disorder is being taught about alprazolam by a nurse. Which of the following information should the nurse include in the teaching?

• A. This medication may increase your blood pressure
• B. Use a reliable form of contraception while taking this medication
• C. If a dose is missed, double the next dose of medication
• D. Do not eat aged cheeses while taking this medication

Correct answer: B

Rationale: The correct answer is B. Alprazolam can increase the risk of pregnancy complications, so using a reliable form of contraception is essential to prevent unintended pregnancies. Choice A is incorrect because alprazolam typically does not increase blood pressure. Choice C is incorrect as doubling the next dose after a missed dose can lead to overdose and adverse effects. Choice D is unrelated to alprazolam and is not a concern when taking this medication.

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