Nursing Elites

1. While assessing a migrant farm worker in a mobile health clinic, which of the following findings should the nurse identify as the priority?

• A. Report of back pain associated with twisting at the waist
• B. Absence of a dental health provider
• C. Lives in a home with 25 other migrant workers
• D. Report of muscle twitching and skin rash

Correct answer: D

Rationale: The correct answer is D because muscle twitching and a rash could indicate pesticide poisoning, a serious condition that requires immediate attention in a migrant farm worker. Option A is not the priority as it could be musculoskeletal in nature and managed after addressing urgent issues. Option B, absence of a dental health provider, though important for overall health, is not an immediate priority. Option C, living with 25 other migrant workers, raises concerns about living conditions but does not present an immediate health threat compared to potential pesticide poisoning.

2. A newly licensed nurse is giving a change-of-shift report using I-SBAR to an oncoming nurse. Which of the following statements by the newly licensed nurse should be included in the 'Background' portion of the report?

• A. The client has a new prescription for incentive spirometry
• B. The client's partner plans to return later today
• C. The client has no living family members
• D. I initiated a consultation with a nutritionist

Correct answer: C

Rationale: In the 'Background' portion of the report, the nurse should include relevant historical information about the client, such as the fact that the client has no living family members. This information helps provide a more comprehensive understanding of the client's situation. Choices A, B, and D are not typically included in the 'Background' section as they do not pertain to the client's history or background.

3. Which intervention is most effective in preventing postoperative complications?

• A. Encourage the patient to drink fluids.
• B. Ambulate the patient as soon as possible.
• C. Perform deep breathing exercises with the patient.
• D. Encourage the patient to perform range of motion exercises.

Correct answer: B

Rationale: The most effective intervention in preventing postoperative complications is to ambulate the patient as soon as possible. Early ambulation helps prevent complications like deep vein thrombosis and pneumonia by enhancing circulation and preventing respiratory issues. Encouraging the patient to drink fluids, perform deep breathing exercises, or range of motion exercises are beneficial interventions, but ambulation is the priority due to its overall impact on preventing various postoperative complications.

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. 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.

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