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A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the specimen in a clean specimen cup.
- B. Remove 45 mL of urine from the catheter with a syringe.
- C. Clamp the catheter tubing below the needleless port.
- D. Clamp the catheter tubing for 60 min.
Correct Answer: C
Rationale: Clamping below the port ensures a fresh, uncontaminated sample.
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A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
- A. Use a catheter securing device to hold the catheter in place.
- B. Obtain urine from the drainage bag if a urinary specimen is required.
- C. Change the catheter bag every 3 days and as needed.
- D. Position the drainage bag higher than the client's bladder.
Correct Answer: A
Rationale: Securing the catheter prevents movement and reduces infection risk.
A charge nurse is observing a newly licensed nurse who is caring for a group of clients. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?
- A. I will use disinfectant to clean the blood pressure cuff after use on a client.
- B. I will double-bag a client's linens each day.
- C. I will wear sterile gloves when bathing a client who is incontinent.
- D. I will rinse the contaminants from a bedpan with hot water.
Correct Answer: A
Rationale: Disinfecting the cuff reduces cross-contamination, aligning with infection control standards.
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client receives burns from a heating pad.
- B. A client reports being dissatisfied with the temperature of the meals provided.
- C. A client becomes disoriented and falls out of bed.
- D. A client’s visitor becomes dizzy and faints in the client's room.
- E. A client is unable to afford the physical therapy that the provider recommends.
Correct Answer: A,C,D
Rationale: A: Injury requires reporting. C: Fall indicates safety issue. D: Visitor incident needs documentation.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Protects skin. D: Monitors for issues. E: Prevents overly tight restraints.
A nurse is assisting in the care of a 72-year-old female client who recently had a stroke and is being monitored for complications. Complete the following sentence by using the lists of options. The client is at risk for developing ___ due to ___.
- A. Deep vein thrombosis (DVT)
- B. Prolonged immobility
- C. Urinary Catheter
- D. constipation
Correct Answer: A,B
Rationale: A: DVT is a risk post-stroke. B: Immobility increases clotting risk.