Nokea
A nurse is inserting an indwelling urinary catheterfor a male patient. Which action will the nurse take?
- A. Hold the shaft of the penis at a 60-degree angle.
- B. Hold the shaft of the penis with the dominant hand.
- C. Cleanse the meatus 3 times with the same cotton ball from clean to dirty.
- D. Cleanse the meatus with circular strokes beginning at the meatus and working outward.
Correct Answer: D
Rationale: The correct answer is D because cleansing the meatus with circular strokes starting at the meatus and moving outward helps prevent the introduction of bacteria into the urethra. This technique minimizes the risk of urinary tract infections. Holding the shaft at a 60-degree angle (A) or with the dominant hand (B) is not necessary for catheter insertion. Cleansing the meatus 3 times with the same cotton ball (C) can introduce more bacteria and is not recommended.
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Which finding would indicate concealed hemorrhage in abruptio placentae?
- A. Bradycardia
- B. Hard boardlike abdomen
- C. Decrease in fundal height
- D. Decrease in abdominal pain
Correct Answer: B
Rationale: The correct answer is B: Hard boardlike abdomen. In abruptio placentae, concealed hemorrhage can lead to blood accumulating behind the placenta, causing the uterus to become tense and rigid, resulting in a hard boardlike abdomen. This finding indicates significant internal bleeding and requires immediate medical attention.
Rationale:
A: Bradycardia is a slow heart rate and is not typically associated with concealed hemorrhage in abruptio placentae.
C: Decrease in fundal height may indicate intrauterine growth restriction, not specifically concealed hemorrhage.
D: Decrease in abdominal pain is not a typical indicator of concealed hemorrhage; in fact, pain may increase due to the increased pressure in the uterus from the bleeding.
The nurse is providing home care for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which dietary intervention will the nurse add to the care plan?
- A. Provide small, frequent nutrient-dense meals for maximizing kilocalories.
- B. Prepare hot meals because they are more easily tolerated by the patient.
- C. Avoid salty foods and limit liquids to preserve electrolytes.
- D. Encourage intake of fatty foods to increase caloric intake.
Correct Answer: A
Rationale: The correct answer is A because providing small, frequent nutrient-dense meals helps maximize kilocalories, which is important for patients with AIDS who may have difficulty maintaining weight due to their compromised immune system. This approach ensures the patient receives essential nutrients and energy to support their immune function.
Choice B is incorrect as there is no evidence to suggest that hot meals are more easily tolerated by AIDS patients.
Choice C is incorrect because limiting liquids can lead to dehydration, which is especially detrimental for individuals with weakened immune systems.
Choice D is incorrect as encouraging the intake of fatty foods may not necessarily provide the necessary nutrients and energy required for immune support in AIDS patients.
A woman scheduled for a simple mastectomy in one week is having her preoperative education provided by the clinic nurse. What educational intervention will be of primary importance to prevent hemorrhage in the postoperative period?
- A. Limit her intake of green leafy vegetables.
- B. Increase her water intake to 8 glasses per day.
- C. Stop taking aspirin.
- D. Have nothing by mouth for 6 hours before surgery.
Correct Answer: C
Rationale: The correct answer is C: Stop taking aspirin. Aspirin is a blood thinner that can increase the risk of bleeding during and after surgery. By stopping aspirin before surgery, the woman's blood clotting ability will improve, reducing the risk of hemorrhage.
A: Limiting intake of green leafy vegetables is not directly related to preventing hemorrhage in the postoperative period.
B: Increasing water intake is important for overall health, but it does not specifically address the risk of hemorrhage related to aspirin use.
D: Having nothing by mouth for 6 hours before surgery is important for preventing aspiration during anesthesia, but it does not directly address the risk of hemorrhage related to aspirin use.
A patient with Parkinsons disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patients nutritional needs should be met by what method?
- A. Total parenteral nutrition (TPN)
- B. Provision of a low-residue diet
- C. Semisolid food with thick liquids
- D. Minced foods and a fluid restriction
Correct Answer: C
Rationale: The correct answer is C: Semisolid food with thick liquids. Patients with Parkinson's disease often have dysphagia, leading to aspiration and respiratory complications. Semisolid food with thick liquids helps prevent aspiration and promotes safer swallowing. TPN (A) is not necessary for meeting nutritional needs unless the patient cannot tolerate oral intake. A low-residue diet (B) may not address the specific swallowing issues in Parkinson's disease. Minced foods and fluid restriction (D) may not provide adequate nutrition and hydration.
Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient?
- A. Ask the patient to repeat what was said in order to evaluate understanding.
- B. Stand directly in front of the patient to facilitate lip reading.
- C. Reduce environmental noise and distractions before communicating.
- D. Raise the voice to project sound at a higher frequency.
Correct Answer: C
Rationale: The correct answer is C: Reduce environmental noise and distractions before communicating. This intervention is most likely to facilitate effective communication with a hearing-impaired patient because it creates an optimal environment for the patient to better focus on the communication. By reducing noise and distractions, the patient can more easily concentrate on the conversation and lip reading, if needed. This approach demonstrates sensitivity to the patient's needs and enhances the chances of successful communication.
The other choices are incorrect because:
A: Asking the patient to repeat what was said may cause frustration and does not address the environmental factors that can hinder communication.
B: Standing directly in front of the patient to facilitate lip reading may help, but it does not address the impact of environmental noise and distractions on communication.
D: Raising the voice to project sound at a higher frequency is not effective as it can distort speech and may not necessarily improve understanding for a hearing-impaired patient.