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The physician has ordered a culture specimen from a client with a suspected urinary tract infection. The nurse is aware that the specimen should be obtained:
- A. From the first morning voiding
- B. Using a sterile cotton ball placed in the client's vaginal area
- C. From the client's indwelling catheter port
- D. During the client's midstream voiding
Correct Answer: D
Rationale: Midstream voiding provides a clean-catch urine specimen for UTI culture, minimizing contamination first voiding risks sediment, vaginal cotton is irrelevant, and catheter ports are for indwelling cases. Nurses instruct this technique, ensuring accurate pathogen identification, critical for effective treatment.
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Which assessment finding indicates a potential complication of immobility related to the respiratory system?
- A. Increased muscle strength
- B. Increased lung expansion
- C. Diminished breath sounds
- D. Normal respiratory rate
Correct Answer: C
Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.
Mr. Gary moved from hospital to rehab with a care plan. This is an example of?
- A. Care transition
- B. Chronic disease management
- C. Health promotion
- D. Nursing informatics
Correct Answer: A
Rationale: Moving from hospital to rehab with a plan is care transition (A) setting shift, per definition. Management (B) ongoing, promotion (C) preventive, informatics (D) tech not transition-specific. A fits care handoff, making it correct.
What can you expect from Marianne, who is currently at the ONSET stage of fever?
- A. Hot, flushed skin
- B. Increase thirst
- C. Convulsion
- D. Pale,cold skin
Correct Answer: D
Rationale: Fever's onset (chill phase) features vasoconstriction e.g., pale, cold skin as the body raises its setpoint. Hot, flushed skin (flush phase), thirst (later), or convulsions (hyperpyrexia) follow. Nurses expect this initial response e.g., shivering in Marianne, guiding warming measures, per fever physiology.
An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has iron deficiency anemia. Because iron deficiency anemia is suspected, which of the following is the most important information to obtain from the infant's parents?
- A. Normal dietary intake
- B. Relevant socio cultural, economic, and educational background of the family
- C. Any evidence of blood in the stools
- D. A history of maternal anemia during pregnancy
Correct Answer: A
Rationale: Dietary intake reveals iron sources, critical for diagnosing deficiency.
A client with chronic obstructive pulmonary disease (COPD) presents with severe dyspnea and hypoxemia. What is the appropriate indication for initiating oxygen therapy in this client?
- A. Maintaining oxygen saturation above 95%
- B. Correcting underlying lung pathology
- C. Relieving shortness of breath
- D. Preventing complications of hypoxia
Correct Answer: D
Rationale: Preventing complications of hypoxia (D) is the primary indication for oxygen therapy in COPD with severe dyspnea and hypoxemia, averting tissue damage and organ failure (target SpO2 88-92%). Saturation above 95% (A) risks CO2 retention in COPD. Correcting pathology (B) requires other treatments. Relieving dyspnea (C) is a benefit, not the goal. Hypoxia prevention aligns with GOLD guidelines, prioritizing survival and function over symptom relief alone.