Nursing Elites

1. The nurse is caring for a client with an indwelling urinary catheter. What is the most important action to prevent catheter-associated urinary tract infections (CAUTI)?

• A. Perform hand hygiene before and after handling the catheter
• B. Change the catheter every 72 hours
• C. Apply antibiotic ointment at the insertion site
• D. Irrigate the catheter daily

Correct answer: A

Rationale: Performing hand hygiene before and after handling the catheter is crucial in preventing catheter-associated urinary tract infections (CAUTI). This practice helps minimize the risk of introducing harmful microorganisms into the urinary tract. Changing the catheter every 72 hours is not recommended unless clinically indicated as it can increase the risk of infection. Applying antibiotic ointment at the insertion site is not a standard practice and may contribute to antibiotic resistance. Irrigating the catheter daily is unnecessary and can introduce pathogens into the urinary tract, increasing the risk of infection.

2. During a severe asthma exacerbation in a client, what is the nurse's priority?

• A. Administer a rescue inhaler immediately
• B. Prepare for intubation
• C. Encourage deep breathing exercises
• D. Monitor oxygen saturation levels

Correct answer: A

Rationale: During a severe asthma exacerbation, the nurse's priority is to administer a rescue inhaler immediately. This action helps open the airways and improve breathing, which is crucial in managing the exacerbation. Choice B, preparing for intubation, would be considered if the client's condition deteriorates and they are unable to maintain adequate oxygenation even after using the rescue inhaler. Encouraging deep breathing exercises (Choice C) may not be appropriate during a severe exacerbation as the client may struggle to breathe. While monitoring oxygen saturation levels (Choice D) is important, the immediate administration of a rescue inhaler takes precedence to address the acute breathing difficulty.

3. The nurse is assessing a client with cirrhosis who has developed ascites. What is the most important intervention to include in the care plan?

• A. Restrict sodium intake
• B. Encourage high-protein meals
• C. Increase fluid intake
• D. Administer diuretics as prescribed

Correct answer: D

Rationale: The correct answer is to administer diuretics as prescribed. Diuretics are often prescribed to help manage fluid accumulation in ascites, which is a common complication of cirrhosis. Restricting sodium intake (Choice A) is essential in managing ascites, but administering diuretics takes precedence in the care plan. Encouraging high-protein meals (Choice B) and increasing fluid intake (Choice C) are not the primary interventions for managing ascites in cirrhosis.

4. Based on the documentation in the medical record, which action should the nurse implement next?

• A. Administer the rubella vaccine subcutaneously
• B. Observe the mother breastfeeding her infant
• C. Call the nursery for the infant's blood type result
• D. Administer Vicodin one tablet for pain

Correct answer: B

Rationale: The correct answer is to observe the mother breastfeeding her infant. This action is essential to ensure that the infant is feeding well and to assess maternal-infant bonding. Administering the rubella vaccine subcutaneously (Option A) is not the immediate priority in this scenario as assessing breastfeeding is more crucial. Calling the nursery for the infant's blood type result (Option C) is premature and not the next appropriate step, as it does not address the immediate needs of the newborn. Administering Vicodin one tablet for pain (Option D) is not indicated without further assessment or indication of pain, making it an incorrect choice at this time.

5. The healthcare provider plans to assess a newborn and check the infant's Moro reflex. What is the healthcare provider evaluating?

• A. Neurological integrity
• B. Renal functioning
• C. Thermoregulation
• D. Respiratory adequacy

Correct answer: A

Rationale: The Moro reflex is an instinctive response observed in newborns, indicating their neurological integrity. This reflex is evaluated by eliciting a startle response in the infant, involving the sudden extension and abduction of the limbs, followed by their retraction. This assessment helps in determining the proper functioning of the infant's nervous system and brain. Choices B, C, and D are incorrect as they do not relate to the evaluation of the Moro reflex. Renal functioning pertains to kidney function, thermoregulation refers to temperature control, and respiratory adequacy involves assessing breathing and oxygenation levels, none of which are evaluated through the Moro reflex.

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