Nursing Elites

1. To obtain a sterile urine specimen from a client with a Foley catheter, the nurse begins by applying a clamp to the drainage tubing distal to the injection port. What does the nurse do next?

• A. Clamp another section of the tube to create a fixed sample section for retrieval.
• B. Insert a syringe into the injection port and aspirate the quantity of urine required.
• C. Clean the injection port cap of the drainage tubing with povidone-iodine solution.
• D. Withdraw 10 mL of urine and discard it; then withdraw 10 mL more for the sample.

Correct answer: C

Rationale: After clamping the drainage tubing, the next step in obtaining a sterile urine specimen from a client with a Foley catheter is to clean the injection port cap of the drainage tubing with povidone-iodine solution. This cleaning step helps prevent contamination of the urine sample. Clamping another section of the tube isn't necessary and may not be a standard practice. Inserting a syringe into the injection port to aspirate urine isn't the correct step at this point. Withdrawing 10 mL of urine and discarding it before collecting the sample isn't appropriate and may lead to an inaccurate sample.

2. A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?

• A. Pupil response
• B. Motor function
• C. Respiratory status
• D. Short-term memory

Correct answer: C

Rationale: In a client with a head injury, assessing the respiratory status is the priority as airway and breathing are essential for life. Immediate attention to respiratory status is crucial to ensure adequate oxygenation. While assessing pupil response and motor function are also important in head injuries, ensuring the client's ability to breathe takes precedence. Short-term memory assessment is not a priority in the emergent phase of care for a client with a head injury.

3. The healthcare professional is assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?

• A. Absence of pedal edema in the lower legs.
• B. Absence of complaints of sexual dysfunction.
• C. No indication of renal impairment.
• D. Blood pressure reading of 148/94 mm Hg.

Correct answer: C

Rationale: The correct answer is 'No indication of renal impairment.' Effective hypertension management aims to prevent complications such as renal impairment. Checking for signs of kidney issues, like abnormal renal function tests, is crucial in monitoring the client's condition. Choices A, B, and D are not specific indicators of effective hypertension management. Pedal edema, sexual dysfunction, and a single blood pressure reading are important but do not solely determine the effectiveness of managing hypertension.

4. A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts the nurse to the possibility of a complication from the UTI?

• A. Burning on urination
• B. Cloudy, dark urine
• C. Fever and chills
• D. Hematuria

Correct answer: C

Rationale: Fever and chills are systemic symptoms that may indicate a more severe infection or a complication of a urinary tract infection (UTI). While burning on urination and cloudy, dark urine are common symptoms of UTI, fever and chills suggest a more serious condition requiring immediate attention. Hematuria, which is blood in the urine, is also a concerning symptom but is more indicative of inflammation or infection rather than a complication.

5. A client is diagnosed with varicella (chickenpox). The nurse places the client on which precautions?

• A. Airborne
• B. Standard
• C. Contact
• D. Droplet

Correct answer: A

Rationale: The correct answer is 'Airborne.' Varicella (chickenpox) is caused by the varicella-zoster virus, which spreads through the air by respiratory droplets. Therefore, placing the client on airborne precautions is necessary to prevent the transmission of the virus. Choice B, 'Standard precautions,' involve basic infection prevention measures that are used for all client care. Choice C, 'Contact precautions,' are used for diseases that spread by direct or indirect contact. Choice D, 'Droplet precautions,' are implemented for diseases transmitted by respiratory droplets that are larger than 5 microns.

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