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A nurse is providing care to a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent catheter-associated urinary tract infections (CAUTIs)?
- A. Irrigate the catheter with sterile water daily.
- B. Empty the catheter bag every 8 hours.
- C. Clean the perineal area with antiseptic solution daily.
- D. Secure the catheter to the client's thigh.
Correct Answer: D
Rationale: Securing the catheter to the client's thigh is the correct action to prevent CAUTIs. By securing the catheter, movement is minimized, reducing the risk of introducing bacteria into the urinary tract. Choice A is incorrect because routine irrigation of the catheter is not recommended as it can increase the risk of infection. Choice B is incorrect as emptying the catheter bag every 8 hours is important for proper drainage but does not directly prevent CAUTIs. Choice C is incorrect because cleaning the perineal area with antiseptic solution does not address the main source of CAUTIs related to catheter care.
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To use the nursing process correctly, what must the nurse do first?
- A. Obtain information about the client
- B. Develop a care plan
- C. Implement interventions
- D. Evaluate the client's outcomes
Correct Answer: A
Rationale: The first step in the nursing process is to obtain information about the client. This step involves gathering data through assessment to understand the client's needs, health status, and preferences. Developing a care plan (Choice B) comes after the assessment phase. Implementing interventions (Choice C) and evaluating client outcomes (Choice D) occur in subsequent stages of the nursing process. Therefore, the correct initial step is to gather information about the client to form a foundation for providing individualized care.
While caring for a client receiving parenteral fluid therapy via a peripheral IV catheter, after which of the following observations should the nurse remove the IV catheter?
- A. Swelling and coolness are observed at the IV site.
- B. The client reports mild discomfort at the insertion site.
- C. The infusion rate is slower than expected.
- D. The IV catheter is no longer needed for treatment.
Correct Answer: A
Rationale: Swelling and coolness at the IV site can indicate complications such as infiltration, which can lead to tissue damage or fluid leakage into the surrounding tissues. Prompt removal of the IV catheter is essential to prevent further complications. The client reporting mild discomfort at the insertion site is common during IV therapy and does not necessarily warrant catheter removal unless there are signs of infiltration. A slower than expected infusion rate may not always necessitate IV catheter removal; the nurse should troubleshoot potential causes such as kinks in the tubing or pump malfunctions first. Just because the IV catheter is no longer needed for treatment does not automatically mean it should be removed; proper assessment and monitoring for complications are still essential.
During the initial physical assessment of a newly admitted client with a pressure ulcer, an LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?
- A. The nurse should have also initiated a plan to increase activity.
- B. The nurse provided supportive nursing care for the well-being of the client.
- C. Debridement of the pressure ulcer should have been performed before applying the dressing.
- D. Treatment should not have been initiated until the healthcare provider's prescriptions were received.
Correct Answer: B
Rationale: The correct answer is B. Providing supportive nursing care, such as applying emollients and reinforcing the dressing on the pressure ulcer, meets the immediate needs of the client and is in line with legal and professional standards. Option A is incorrect because increasing activity may not be directly related to the immediate skin care needs of the client. Option C is incorrect as debridement might not be immediately necessary based on the initial assessment. Option D is incorrect as nurses are often authorized to initiate treatments within their scope of practice without waiting for healthcare provider prescriptions, especially for routine care like skin moisturization and dressing reinforcement.
While auscultating the anterior chest of a client newly admitted to a medical-surgical unit, a nurse listens to the audio clip of breath sounds through her stethoscope. What type of breath sounds does the nurse hear?
- A. Crackles
- B. Rhonchi
- C. Friction rub
- D. Normal breath sounds
Correct Answer: D
Rationale: The correct answer is D: Normal breath sounds. In the scenario described, the nurse hears normal bronchovesicular breath sounds, which are moderate in intensity and resemble blowing as air moves through the larger airways during inspiration and expiration. Crackles (choice A) are typically heard in conditions like heart failure or pneumonia and are not present in this case. Rhonchi (choice B) are low-pitched, continuous sounds often associated with conditions like chronic bronchitis or bronchiectasis. Friction rub (choice C) is a grating sound usually heard in conditions like pleurisy or pericarditis, which is not the case here where normal breath sounds are heard.
The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?
- A. Encourage the patient to engage in self-care.
- B. Promote mobility in the patient.
- C. Encourage the patient to perform range of motion exercises.
- D. Assist the patient with comfort measures.
Correct Answer: D
Rationale: The priority action for a patient with Impaired physical mobility related to pain is to assist the patient with comfort measures. By addressing pain through comfort measures, the patient will be more willing and able to move. Encouraging self-care (Choice A) may be important but addressing pain first is crucial in improving mobility. Promoting mobility (Choice B) and encouraging range of motion exercises (Choice C) are important but addressing the pain and providing comfort measures take precedence to improve the patient's physical mobility.