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The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the RN?
- A. The patient states she feels the need to urinate.
- B. Patient reports a pinching sensation as the catheter is advanced.
- C. The student nurse notes resistance when inflating the balloon.
- D. The student separates the labia majora and labia minora with non-dominant hand.
Correct Answer: C
Rationale: Resistance when inflating the catheter balloon (C) suggests improper placement (e.g., in urethra), risking trauma, requiring immediate RN intervention. Urge to urinate (A) and pinching (B) are normal, and labia separation (D) is correct technique.
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The nurse is teaching a leadership and management course and is discussing client referrals. Which of the following statements best describes the purpose of referrals?
- A. Allows the nurse to demonstrate their leadership abilities.
- B. Care is appropriately routed to an individual or discipline.
- C. Ensures that care is unilateral and cost-effective.
- D. Focuses on empowering the client's decision making.
Correct Answer: B
Rationale: Referrals (B) ensure care is directed to the appropriate specialist or discipline to meet the client’s needs effectively. Demonstrating leadership (A) is secondary. Referrals do not ensure unilateral care (C) and are not primarily about client empowerment (D), though they may support it.
The nurse is conducting a teaching session with the parents of a child newly diagnosed with asthma. The priority topic for the nurse to cover is
- A. how to use a peak flow meter.
- B. signs and symptoms of an asthma attack.
- C. the need to stay current with immunizations.
- D. community resources available for asthma management.
Correct Answer: B
Rationale: Recognizing signs and symptoms of an asthma attack (B) is critical for parents to initiate prompt intervention, preventing severe exacerbations. Peak flow meter use (A), immunizations (C), and community resources (D) are important but secondary to immediate safety education.
The infection control nurse delegates tasks to staff to reduce hospital-acquired infections. Which task would be appropriate to delegate to the unlicensed assistive personnel (UAP)?
- A. Educate staff members on actions to reduce central line-associated bloodstream infections
- B. Demonstrating correct handwashing techniques to visitors
- C. Restocking personal protective equipment (PPE)
- D. Screening visitors for respiratory infections
Correct Answer: C
Rationale: Restocking PPE (C) is a non-clinical task within the UAP’s scope. Educating staff (A), demonstrating handwashing (B), and screening visitors (D) require clinical judgment or training, inappropriate for UAPs.
A nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which task is most appropriate for the UAP to perform?
- A. Assisting a client with dysphagia during oral feedings.
- B. Documenting a client’s response to a medication administered for pain relief.
- C. Collecting a clean-catch urine sample from a client.
- D. Removing a client’s indwelling urinary catheter per the provider’s order.
Correct Answer: C
Rationale: Collecting a clean-catch urine sample (C) is a non-invasive task within the UAP’s scope. Feeding with dysphagia (A), documenting medication response (B), and catheter removal (D) require clinical judgment or training beyond UAP scope.
The emergency department (ED) nurse is caring for an infant who is choking on a foreign object. On assessment, the infant is conscious and not making any noises. The nurse should immediately
- A. begin chest compressions at 100-120/minute.
- B. attempt a blind finger sweep in the mouth.
- C. perform abdominal thrusts.
- D. give five back blows and five chest thrusts.
Correct Answer: D
Rationale: For a conscious choking infant, five back blows followed by five chest thrusts (D) is the standard intervention to dislodge the foreign object, per pediatric advanced life support guidelines. Chest compressions (A) are for unresponsive infants, blind finger sweeps (B) risk pushing the object deeper, and abdominal thrusts (C) are not used in infants due to injury risk.