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. When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse’s best intervention?

• A. Call the healthcare provider and report the finding.
• B. Reassess the client’s blood pressure at the next follow-up appointment.
• C. Administer an additional antihypertensive medication to the client.
• D. Teach the client lifestyle modifications to decrease blood pressure.

Correct answer: D

Rationale: The correct answer is to teach the client lifestyle modifications to decrease blood pressure. A blood pressure reading of 134/88 mm Hg falls within the prehypertension range. The initial approach to managing prehypertension involves lifestyle modifications such as dietary changes, exercise, and stress reduction techniques. Calling the healthcare provider without attempting non-pharmacological interventions first is premature. Reassessing blood pressure at the next follow-up appointment may delay necessary interventions. Administering additional antihypertensive medication is not indicated at this stage as lifestyle modifications are the first line of treatment for prehypertension.

3. The healthcare provider is assessing a client before surgery. Which assessments contraindicate the client from having surgery as scheduled? (Select one that does not apply.)

• A. Potassium level of 2.8 mEq/L
• B. International normalized ratio (INR) of 4
• C. Prothrombin time (PT) of 30 seconds
• D. Positive pregnancy test

Correct answer: C

Rationale: The correct answer is C: Prothrombin time (PT) of 30 seconds. A low potassium level (choice A) and an elevated INR (choice B) indicate potential bleeding risks during surgery. A positive pregnancy test (choice D) in a female client can lead to complications during surgery. However, a Prothrombin time of 30 seconds is within the normal range and does not contraindicate the client from having surgery as scheduled.

4. 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.

5. How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?

• A. Poor left-sided motor control
• B. Paralysis or contractures on the right side
• C. Limited visual perception of the left fields
• D. Unawareness of the existence of her left side

Correct answer: D

Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.

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