Nursing Elites

1. A healthcare professional is preparing to insert an indwelling urinary catheter. What is the most important action to prevent infection?

• A. Use sterile gloves during the procedure.
• B. Clean the catheter insertion site with alcohol.
• C. Insert the catheter as quickly as possible.
• D. Use a smaller catheter size to minimize trauma.

Correct answer: A

Rationale: Using sterile gloves during catheter insertion is crucial to prevent infection. Sterile gloves help maintain asepsis during the procedure, reducing the risk of introducing microorganisms into the urinary tract. Cleaning the insertion site with alcohol, as mentioned in choice B, is important but not as critical as using sterile gloves. Choice C, inserting the catheter as quickly as possible, is not recommended as it can lead to errors and increase the risk of contamination. Choice D, using a smaller catheter size to minimize trauma, is not directly related to preventing infection but rather focuses on patient comfort and reducing tissue damage.

2. A client is about to undergo surgery and is unsure about the procedure despite signing the consent. What should the nurse do?

• A. Reassure the client and proceed with the surgery.
• B. Stop the surgery and consult with the surgeon.
• C. Proceed with the surgery but document the client's concerns.
• D. Postpone the surgery until further clarification is provided.

Correct answer: B

Rationale: When a client expresses doubts about a procedure after signing the consent form, it is crucial to stop the surgery and consult with the surgeon. This is important to ensure that the client's concerns are addressed, and there is a clear understanding of the procedure. Reassuring the client and proceeding with the surgery (choice A) may violate the client's autonomy and right to informed consent. Proceeding with the surgery but documenting the concerns (choice C) is not sufficient as the client's doubts should be resolved before proceeding. Postponing the surgery until further clarification is provided (choice D) may be necessary, but the immediate step should be to consult with the surgeon to address the client's concerns.

3. A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

• A. Irrigate the client's throat every 4 hours
• B. Withhold food and liquids until the client's gag reflex returns
• C. Suction the client's oropharynx frequently
• D. Have the client refrain from talking for 24 hours

Correct answer: B

Rationale: After a flexible bronchoscopy, it is essential to withhold food and liquids until the client's gag reflex returns. This precaution helps prevent aspiration, as the gag reflex protects the airway from foreign material. Irrigating the client's throat every 4 hours (Choice A) is unnecessary and may increase the risk of aspiration. Suctioning the client's oropharynx frequently (Choice C) can cause trauma and is not indicated unless there is a specific medical reason for it. Having the client refrain from talking for 24 hours (Choice D) is not necessary after a flexible bronchoscopy.

4. 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.

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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