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A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the client in a semi-lying position.
- B. Instill 15 mL of irrigation fluid into the catheter with each flush.
- C. Subtract the amount of irrigant used from the client's urine output.
- D. Perform the irrigation using a 20-mL syringe.
Correct Answer: C
Rationale: The correct answer is C: Subtract the amount of irrigant used from the client's urine output. This is the correct action because when using open irrigation technique, the nurse needs to account for the amount of irrigant introduced into the catheter to accurately assess the client's urine output. By subtracting the amount of irrigant used from the total output, the nurse ensures an accurate measurement of the client's urine output. This is crucial for monitoring the client's renal function and fluid balance.
Choice A is incorrect as the client should ideally be in a supine position during catheter irrigation to prevent spillage. Choice B is incorrect as the amount of irrigation fluid instilled should typically be equal to the amount of urine output, not a fixed amount. Choice D is incorrect as a 60-mL syringe is usually recommended for catheter irrigation to avoid excessive force and pressure on the catheter.
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A nurse is caring for a client who has a terminal illness, and the client's partner indicates effective coping. The nurse should recognize that which of the following statements is an indication of effective coping?
- A. I am not worried because I will have hope that he will be okay.
- B. I am relying on support from our family during this time.
- C. We can plan our family reunion once he recovers and comes home.
- D. We don't see any reason to start discussing funeral arrangements right now.
Correct Answer: B
Rationale: The correct answer is B: "I am relying on support from our family during this time." This statement indicates effective coping because it acknowledges the importance of seeking and utilizing support from family members, which can help reduce feelings of isolation and provide emotional strength. By relying on family support, the client's partner is demonstrating a healthy coping mechanism that promotes resilience and emotional well-being during a challenging situation.
Choice A is incorrect because relying solely on hope without acknowledging the need for support may not address the partner's emotional needs effectively. Choice C is incorrect as it demonstrates denial of the terminal illness and avoidance of the current reality. Choice D is incorrect as it suggests avoidance of discussing important end-of-life decisions, which can hinder effective coping and planning.
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
- A. Use the complete name of the medication magnesium sulfate.
- B. Distinguish the space between the numerical dose and the unit of measure.
- C. Write the letter U when noting the dosage of insulin.
- D. Use the abbreviation SC when indicating an injection.
Correct Answer: A
Rationale: The correct answer is A: Use the complete name of the medication magnesium sulfate. This is important because using the complete name of the medication helps prevent medication errors and ensures clarity in communication. It also follows best practices for medication safety.
Choice B is incorrect because while distinguishing the space between the numerical dose and the unit of measure is important for clarity, it is not as critical as using the complete name of the medication.
Choice C is incorrect because when noting the dosage of insulin, it is important to use the unit "units" rather than the letter "U" for accuracy and clarity.
Choice D is incorrect because the correct abbreviation for indicating a subcutaneous injection is "SQ" or "subQ," not "SC."
Overall, using the complete name of the medication is the most crucial aspect in medication documentation to ensure patient safety and prevent errors.
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
- A. Use the Face Legs Activity Cry and Consolability (FLACC) pain rating scale for a client who is experiencing pain.
- B. Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm.
- C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum.
- D. Palpate the client's abdomen before auscultating bowel sounds.
Correct Answer: B
Rationale: The correct answer is B: Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm. This is the correct physical assessment technique because proper cuff placement is essential for accurate blood pressure measurement. Placing the cuff around 50% of the arm circumference ensures that the blood pressure reading is not falsely elevated or decreased. Incorrect choices: A: Using the FLACC pain rating scale is relevant for pain assessment, but not a physical assessment technique. C: Obtaining an apical heart rate by auscultating at the third intercostal space left of the sternum is incorrect as the fifth intercostal space at the midclavicular line is the correct location. D: Palpating the client's abdomen before auscultating bowel sounds is incorrect as bowel sounds should be auscultated first to prevent stimulating peristalsis.
A nurse in a provider's clinic is caring for a client who has diarrhea. The nurse is providing teaching for the client. Select the 4 instructions the nurse should include in the teaching.
- A. Increase intake of high-calcium foods.
- B. Eat probiotic foods, such as yogurt.
- C. Avoid alcohol while experiencing diarrhea.
- D. Eat raw vegetables.
- E. Eat three large meals a day.
- F. Avoid caffeine while experiencing diarrhea.
- G. Drink lots of fluids several times a day.
Correct Answer: B, C, F, G
Rationale: The correct instructions for the nurse to include are B, C, F, and G.
B: Probiotic foods like yogurt can help restore gut health.
C: Alcohol can worsen diarrhea, so it's important to avoid it.
F: Caffeine can be irritating to the digestive system, so avoiding it is beneficial.
G: Drinking lots of fluids helps prevent dehydration from diarrhea.
These instructions are essential for managing diarrhea effectively.
Incorrect options:
A: High-calcium foods may not be well-tolerated during diarrhea.
D: Raw vegetables can be difficult to digest during diarrhea.
E: Eating three large meals can be too much for a digestive system experiencing diarrhea.
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
- B. Regulate oxygen via nasal cannula at flow rate of no more than 6 L/min.
- C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
- D. Use petroleum jelly to lubricate the client's nares face and lips.
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the appropriate action for administering oxygen therapy to prevent oxygen toxicity. Oxygen should be delivered at the lowest effective flow rate to minimize the risk of complications. Choices A, C, and D are incorrect. A is incorrect because the flow rate should be aligned with the bottom of the ball in the flow meter, not the top. C is incorrect because the reservoir bag of a partial rebreathing mask should be inflated to ensure adequate oxygen delivery. D is incorrect because petroleum jelly should not be used in oxygen therapy due to the risk of fire hazard.