A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?

Hearing acuity intact

Oriented to person only

Full range of motion bilateral lower extremities

Ability to use call light

Answer and Explanation

The Correct Answer is B

A)   Hearing acuity intact - Intact hearing acuity does not directly increase the risk for potential client injuries.
B)   Oriented to person only - Being oriented to person only may indicate confusion or disorientation, which can increase the risk for potential client injuries due to impaired decision-making or awareness of surroundings.
C)   Full range of motion bilateral lower extremities - Having a full range of motion in the lower extremities does not directly increase the risk for potential client injuries.
D)   Ability to use call light - The ability to use a call light indicates the client's ability to seek assistance, which reduces the risk for potential client injuries.

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Correct Answer is B

Explanation

A) Place the specimen in a clean specimen cup. - Urine collected from an indwelling urinary catheter should be obtained using a sterile technique, not placed directly into a clean specimen cup.
B) Clamping the catheter tubing for 10–30 minutes before collecting the sample allows fresh urine to accumulate in the tubing, ensuring a more accurate culture result. The urine should be collected from the designated port using aseptic technique, not from the catheter bag, as stagnant urine may contain contaminants.

C) Clamp the catheter tubing for 60 min. - Clamping the tubing for an extended period can cause urinary retention and discomfort for the client. It is not appropriate for collecting a urine specimen.
D) Only 3–5 mL of urine is needed for a culture.The nurse should collect the appropriate small amount to avoid unnecessary removal of urine.

A. Unequal height of the shoulders B. Expansion of the upper intercostal spaces C. Increased convex curve of the cervical spine D. Increased concave curve of the thoracic spine

Correct Answer is A

Explanation

A) Unequal height of the shoulders - This finding is characteristic of scoliosis, as the curvature of the spine may cause one shoulder to appear higher than the other.
B) Expansion of the upper intercostal spaces - Expansion of the intercostal spaces is not a typical finding in scoliosis and may indicate other respiratory or musculoskeletal conditions.
C) Increased convex curve of the cervical spine - While scoliosis can affect the entire spine, an increased convex curve in the cervical spine is not typically associated with scoliosis.
D) Increased concave curve of the thoracic spine - While scoliosis often involves a lateral curvature of the spine, an increased concave curve of the thoracic spine alone may not be indicative of scoliosis.

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A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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