Nursing Elites

1. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

• A. The AP hangs the collection bag below the level of the bladder.
• B. The AP performs hand hygiene before handling the catheter.
• C. The AP secures the catheter to the client’s leg with tape.
• D. The AP empties the collection bag when it is full.

Correct answer: A

Rationale: Hanging the collection bag below the level of the bladder is the correct technique for maintaining proper drainage and preventing backflow in a client with an indwelling urinary catheter. Therefore, choice A is the correct answer as it indicates a need for further teaching. Choices B, C, and D demonstrate appropriate actions in catheter care. Performing hand hygiene before handling the catheter helps prevent infection, securing the catheter to the client’s leg with tape prevents accidental dislodgement, and emptying the collection bag when it is full ensures that the catheter functions effectively.

2. A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client’s room to administer medications and finds the client crying. The appropriate nursing action is to:

• A. Sit and hold the client’s hand
• B. Ask why the client is crying
• C. Leave the room to give the client privacy
• D. Administer the medications and leave

Correct answer: A

Rationale: In end-of-life care, providing comfort and emotional support is essential. Sitting with the client, holding their hand, and offering a compassionate presence can help the client feel supported during a difficult time. Asking why the client is crying may not always be necessary as the focus should be on providing comfort rather than probing for information. Leaving the room to provide privacy or just administering medications and leaving may neglect the client's emotional needs and miss an opportunity to provide holistic care.

3. When providing oral care to an unconscious patient, what action should the nurse take to protect the patient from injury?

• A. Moisten the mouth using lemon-glycerin sponges.
• B. Hold the patient's mouth open with gloved fingers.
• C. Use foam swabs to help remove plaque.
• D. Suction the oral cavity.

Correct answer: D

Rationale: When caring for an unconscious patient, it is crucial to prevent choking and aspiration. Suctioning the oral cavity helps in removing secretions and preventing potential harm. Moisten the mouth using lemon-glycerin sponges may not effectively clear secretions. Holding the patient's mouth open with gloved fingers can cause discomfort and potential harm. Using foam swabs to remove plaque may not address the immediate risk of aspiration.

4. A healthcare professional is caring for a group of clients. Which of the following measures should the professional take to prevent the spread of infection?

• A. Place a client with TB in a room with negative pressure airflow
• B. Use a disposable gown for contact precautions
• C. Place a client with MRSA in a private room
• D. Use a mask for clients with influenza

Correct answer: A

Rationale: Tuberculosis is an airborne infection, and placing a client with TB in a room with negative pressure airflow helps prevent the spread of the infection by containing the pathogens. This measure is crucial as it prevents the dissemination of TB droplet nuclei to other areas. Choice B, using a disposable gown for contact precautions, is important for preventing the transmission of infections spread by direct or indirect contact. Choice C, placing a client with MRSA in a private room, is essential to prevent the spread of MRSA through contact with others. Choice D, using a mask for clients with influenza, helps prevent the spread of influenza through respiratory droplets. However, negative pressure airflow is specifically required for airborne infections like TB, making it the most appropriate choice in this scenario.

5. When interviewing the parents of a child with asthma, what information about the child's environment should be gathered most importantly?

• A. Household pets
• B. New furniture
• C. Lead-based paint
• D. Plants such as cactus

Correct answer: A

Rationale: When assessing a child with asthma, it is crucial to gather information about potential triggers in their environment. Household pets, such as cats or dogs, are common triggers for asthma attacks due to pet dander and saliva. This information is essential to identify if exposure to pets at home could be exacerbating the child's asthma symptoms. Choices B, C, and D are less relevant in the context of asthma triggers. New furniture, lead-based paint, and plants like cactus are not typically primary triggers for asthma attacks compared to common allergens like pet dander.

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