1. A homebound patient with ALS using bipap refuses feeding tubes but accepts antibiotics for uti. They have a 9-month prognosis and want to discuss advance directives. Which service provides this support while respecting treatment preferences?
Answer: B
Palliative care supports advance care planning and symptom management without requiring treatment limitations (antibiotics allowed). Prognosis exceeds hospice eligibility (A). Neurology (C) and primary care (D) lack specialized training in complex goals-of-care discussions. The patient’s refusal of feeding tubes but acceptance of antibiotics reflects nuanced decision-making best addressed by palliative teams.
2. A 68-year-old patient with diabetes and limited mobility is admitted for heart failure exacerbation. The nurse notes the patient has been using a urinal independently with 200-300 mL output per void. The night shift placed an indwelling catheter "for accurate I&O measurement" without a documented medical indication. Which action aligns with CAUTI prevention bundles?
Answer: B
CAUTI prevention bundles emphasize catheter removal when no valid indication exists. This patient voids adequate volumes independently, making accurate I&O achievable without an indwelling catheter (CDC guideline). Option A disregards inappropriate placement. Option C delays removal despite absence of infection symptoms. Option D introduces unnecessary infection risk through repeated instrumentation. Diabetes and mobility limitations increase UTI vulnerability, reinforcing the need for prompt removal per AMSN protocols.
3. A medical-surgical unit notes increased catheter-associated UTIs over three months. Nurses report inconsistent insertion documentation. The educator must identify staff learning needs. Which method most effectively differentiates knowledge deficits from system issues?
Answer: D
Focus groups (D) reveal systemic vs. individual gaps by contextualizing documentation lapses with workflow barriers, addressing both infection trends and reported inconsistencies. Option A measures confidence, not actual practice. Option B assesses technical skill but omits documentation processes. Option C identifies data gaps but not their root causes. AMSN guidelines prioritize mixed-method needs assessments to distinguish training deficits from environmental factors impacting quality metrics.
4. A 75-year-old with recurrent UTIs and recent ESBL E. coli cystitis completed 7 days of ertapenem. At follow-up, they report resolved symptoms but fear recurrence. They request long-term prophylaxis. Which response adheres to stewardship?
Answer: C
Stewardship avoids unnecessary antimicrobials, especially for non-recurrent indications. Prophylaxis isn't routinely recommended after single resolved infections due to resistance risks. Asymptomatic bacteriuria rarely requires treatment in elderly patients. Nitrofurantoin (A) and TMP-SMX (B) promote resistance without clear indication. Cranberry (D) lacks consistent evidence for UTI prevention. IDSA guidelines reserve prophylaxis for ≥3 UTIs/year and emphasize avoiding treatment of asymptomatic bacteriuria.
5. A 68-year-old with a subclavian triple-lumen CVAD develops acute dyspnea and tachycardia during dressing change. The nurse notices the injection cap was disconnected briefly. Which action takes precedence?
Answer: B
This positioning traps air in the right ventricle, preventing pulmonary embolism progression. Oxygen (A) supports oxygenation but doesn't address embolism source. Chest X-ray (C) confirms diagnosis but delays life-saving intervention. Clamping (D) may not contain air already in circulation. Air embolism requires immediate positional therapy per INS standards when occurring during catheter manipulation with respiratory symptoms.
6. A nurse reviews CAUTI bundle compliance on a unit with high infection rates. Which audit finding represents the greatest breach in aseptic technique during catheter insertion?
Answer: B
Sterile gloves are mandatory during the entire insertion process to prevent pathogen introduction (CDC CAUTI bundle). Option A doesn’t directly violate asepsis if packets remain sealed. Option C is acceptable within 1-hour kit viability windows. Option D relates to positioning preference, not asepsis. Non-sterile gloves during cleansing contaminate the sterile field, significantly increasing infection risk per AMSN standards.
7. A CQI initiative reduced postoperative urinary retention by implementing nurse-driven bladder scans. Six months later, rates rise slightly. Staff request more scanners. The team’s next step should be:
Answer: B
Rising rates after success (cue: temporal change) warrant checking protocol adherence before resource allocation. Buying scanners (A) addresses supply without verifying need. Surveys (C) are subjective; chart review provides objective data. Benchmarking (D) contextualizes but doesn’t diagnose the local problem. CQI prioritizes process verification over assumptions.
8. Three days post-admission, a diabetic patient receiving vancomycin via a forearm IV reports burning pain. Assessment reveals erythema extending 3 cm from the site, warmth, and a palpable venous cord. Which action aligns with current INS phlebitis management guidelines?
Answer: C
Erythema >1 cm with cord and pain indicates Grade 3 phlebitis per INS scale, requiring catheter removal. Warm compresses promote vasodilation and healing. Cold compresses (A) worsen vasoconstriction. Vancomycin is irritant-related, not infectious, making cultures (D) unnecessary without systemic signs. Monitoring without removal (B) risks progression. Diabetes increases infection risk, necessitating prompt removal.
9. A paraplegic patient (T4 injury) with a stage 2 sacral pressure injury develops autonomic dysreflexia during dressing changes. Which care plan revision is most individualized?
Answer: B
Autonomic dysreflexia triggers (like wound care) require preemptive noxious stimulus control. Topical anesthetics (B) directly address pain from debridement (Consortium for Spinal Cord Medicine). Lorazepam (A) reduces anxiety but doesn't block pain triggers. Oxybutynin (C) prevents bladder spasms but isn't procedure-specific. Nitroglycerin (D) treats hypertension emergently but doesn't prevent episodes. Cues (T4 injury, pressure injury) prioritize targeted pain prevention during known triggers to avert dysreflexia.
10. The unit's budget allows one major equipment purchase. Options include: a $12k bladder scanner reducing catheterizations, a $10k lift reducing injury claims, or a $15k telemetry upgrade for arrhythmia detection. Data show 14 avoidable catheterizations/month and 2 staff injuries/quarter, but no telemetry-related incidents. Which purchase has the strongest ROI justification?
Answer: A
Option A addresses high-frequency avoidable catheterizations (14/month), preventing CAUTIs costing ~$1,000 each and reducing supply use. The lift (B) targets infrequent injuries (2/quarter), offering slower ROI. Telemetry (C) lacks supporting incident data, making ROI unproven. Deferring (D) ignores equipment’s long-term savings. Cues (avoidable catheterization rate, no telemetry incidents) prioritize the bladder scanner: it directly reduces recurrent costs, aligning with value-based purchasing principles.
11. An obese patient receiving hypertonic TPN via a peripheral IV exhibits sudden swelling 2 cm beyond the site without redness or pain. The skin is taut but compressible, and infusion resistance is high. What complication is most likely?
Answer: B
Swelling beyond site with increased resistance indicates infiltration. Absence of erythema/pain rules out phlebitis (A). Hypertonic solutions increase infiltration risk. Taut skin suggests fluid accumulation, not thrombosis (C) or nerve issues (D). Obesity obscures assessment cues; INS standards require vigilance for subtle signs. Catheter dislodgement is common with movement in obese patients.
12. An 82-year-old man with a history of Alzheimer's dementia, recurrent UTIs, and chronic constipation is brought in for increased confusion. Medications include donepezil 10mg nightly, citalopram 20mg daily, oxybutynin 5mg TID for bladder spasms, polyethylene glycol daily, and a recent 7-day course of ciprofloxacin completed 2 days ago. His MMSE score is now 18 (down from 22). Which medication is MOST likely contributing to the acute cognitive decline?
Answer: C
Oxybutynin is a potent anticholinergic, strongly linked to delirium and cognitive impairment in older adults, especially those with baseline dementia (Alzheimer's). Polypharmacy (multiple CNS-active drugs) and recent illness (UTI) heighten vulnerability. Option A: Donepezil is a cholinesterase inhibitor (pro-cholinergic), not likely to cause decline. Option B: Citalopram 20mg is at the max geriatric dose and can rarely cause hyponatremia, but anticholinergics like oxybutynin are a more common and potent deliriogenic. Option D: Ciprofloxacin can cause CNS effects, but they typically resolve after stopping; ongoing anticholinergic effect is more probable.
13. An oncology patient with neutropenia has an EWS of 4 (temp 38.0°C, RR 20/min). Which additional parameter should increase their EWS score to 7?
Answer: B
A 30mmHg SBP drop indicates sepsis-induced hypotension in neutropenia, adding 3 EWS points (total 7), triggering rapid response. Option B meets SBP criteria for significant scoring change. Option A adds 2 points for supplemental oxygen (total 6). Option C suggests UTI but no vital sign change for extra points. Option D adds 2 points for tachycardia (total 6). EWS algorithms assign higher points for hypotension in immunocompromised patients due to sepsis mortality risk.
14. A nurse manager seeks evidence to reduce catheter-associated UTIs in elderly patients with cognitive impairment. Resources include a meta-analysis of RCTs on nurse-led catheter protocols, a case-control study on risk factors, and expert consensus guidelines. Which source aligns with the highest evidence tier for practice change?
Answer: A
Meta-analyses of RCTs (A) represent the highest tier by synthesizing multiple experimental studies—essential for infection control in vulnerable elderly. The case-control study (B) is observational and lower-tier. Guidelines (C) may incorporate high-level evidence but are secondary; consensus alone is low-tier. Option D ignores hierarchy principles. Cognitive impairment demands rigorous evidence to avoid harm, making A optimal.
15. A 68-year-old patient with diabetes mellitus and a history of Clostridium difficile infection is admitted for pneumonia. The nurse prepares to insert a urinary catheter using the CAUTI prevention bundle. Which action best aligns with current bundle guidelines for this patient?
Answer: C
C is correct: CDC CAUTI bundles mandate hand hygiene after glove removal to prevent pathogen transmission, especially critical with C. diff history where contact precautions apply. A is incorrect: Chlorhexidine—not povidone-iodine—is recommended for meatal cleansing. B is incorrect: Silver-coated catheters aren't first-line for short-term use per IDSA guidelines. D is incorrect: Securing to the thigh—not abdomen—prevents urethral traction. The diabetes comorbidity increases UTI risk, reinforcing strict bundle adherence.
