Nursing Elites

1. A nurse is providing care to a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent catheter-associated urinary tract infections (CAUTIs)?

• A. Irrigate the catheter with sterile water daily.
• B. Empty the catheter bag every 8 hours.
• C. Clean the perineal area with antiseptic solution daily.
• D. Secure the catheter to the client's thigh.

Correct answer: D

Rationale: Securing the catheter to the client's thigh is the correct action to prevent CAUTIs. By securing the catheter, movement is minimized, reducing the risk of introducing bacteria into the urinary tract. Choice A is incorrect because routine irrigation of the catheter is not recommended as it can increase the risk of infection. Choice B is incorrect as emptying the catheter bag every 8 hours is important for proper drainage but does not directly prevent CAUTIs. Choice C is incorrect because cleaning the perineal area with antiseptic solution does not address the main source of CAUTIs related to catheter care.

2. A client is experiencing a severe sore throat, pain when swallowing, and swollen lymph nodes. Which of the following stages of infection is the client likely in?

• A. Prodromal
• B. Incubation
• C. Convalescence
• D. Illness

Correct answer: D

Rationale: The client in this scenario is in the illness stage of infection. During this stage, the individual exhibits specific symptoms such as a severe sore throat, pain when swallowing, and swollen lymph nodes. The prodromal stage precedes the appearance of specific symptoms and is characterized by nonspecific signs. The incubation period occurs between exposure to the pathogen and the onset of symptoms. Convalescence is the recovery period following the resolution of the infection. Therefore, the correct answer is 'D: Illness' as it aligns with the symptoms presented by the client.

3. A client with a history of heart failure presents to the clinic with a 2-day history of weight gain, swelling in the legs, and shortness of breath. Which of the following is the most appropriate initial nursing action?

• A. Perform a physical assessment
• B. Review the client's medication list
• C. Instruct the client to elevate the legs
• D. Obtain a detailed dietary history

Correct answer: A

Rationale: Performing a physical assessment is the most appropriate initial nursing action in this scenario. A thorough physical assessment helps evaluate the client's current condition, severity of symptoms, and identify any immediate concerns. This assessment can provide crucial information to guide further interventions and treatment. Reviewing the client's medication list (choice B) is important but may not address the immediate need for assessing the client's current status. Instructing the client to elevate the legs (choice C) may be beneficial but should come after a thorough assessment. Obtaining a detailed dietary history (choice D) is relevant for heart failure management but is not the most urgent initial action when the client presents with acute symptoms like weight gain, leg swelling, and shortness of breath.

4. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved?

• A. Number of staff-induced injuries
• B. Client satisfaction survey
• C. Healthcare-associated infection rate
• D. Rate of needle-stick injuries by nurses

Correct answer: C

Rationale: The correct answer is C: Healthcare-associated infection rate. This measure best indicates the effect of the policy on infection control. By monitoring the healthcare-associated infection rate, it can be determined if the policy of removing acrylic nails has contributed to reducing the risk of infections. Choices A, B, and D are not as directly linked to the outcome of the policy. The number of staff-induced injuries may not be solely due to acrylic nails. Client satisfaction may not be directly impacted by this policy, and needle-stick injuries are more related to a different aspect of healthcare practice.

5. During passive range of motion (ROM) exercises, how should the nurse perform each movement for a patient with impaired mobility?

• A. The nurse moves each movement just to the point of resistance.
• B. The patient repeats each movement 5 times.
• C. The movement continues until the patient reports pain.
• D. The nurse completes each movement quickly and smoothly.

Correct answer: A

Rationale: During passive range of motion (ROM) exercises, the nurse is responsible for moving the patient's joints through their range of motion. The correct technique involves performing movements slowly and smoothly, only going to the point of resistance without causing pain. This technique helps maintain joint flexibility and prevent contractures. Choice A is the correct answer as it reflects the appropriate technique for passive ROM exercises. Choices B and C are incorrect because the patient is not actively participating, and ROM exercises should not cause pain. Choice D is incorrect as movements should be done deliberately and not quickly.

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