Nokea
A client has returned from a cardiac catheterization. Which one of the following findings would indicate the client is experiencing a complication from the procedure?
- A. Increased blood pressure
- B. Increased heart rate
- C. Loss of pulse in the extremity
- D. Decreased urine output
Correct Answer: C
Rationale: Loss of pulse in the extremity. Loss of the pulse in the extremity would indicate impaired circulation.
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A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis?
- A. I knew this would happen. I've been eating too much red meat lately.'
- B. I really enjoyed my fishing trip yesterday. I caught two fish.'
- C. I have really been working hard practicing basketball.'
- D. I went to get a cold checked out last week, and I have gotten worse.'
Correct Answer: D
Rationale: I went to get a cold checked out last week, and I have gotten worse.' Any condition that increases the body's need for oxygen or alters the transport of oxygen, such as infection, trauma or dehydration may result in a sickle cell crisis.
The nurse is caring for the client with a urinary catheter. Which interventions should the nurse implement to prevent a catheter-acquired UTI? Select all that apply.
- A. Rubbing for 10 seconds when using alcohol-based hand rubs
- B. Changing urinary catheters and drainage bags once a week
- C. Using the smallest numbered catheter with intermittent catheterizations
- D. Properly securing the catheter on the client's thigh to prevent movement
- E. Keeping a urinary drainage bag below the level of the client's bladder
Correct Answer: D,E
Rationale: D: Securing the catheter prevents urethral irritation, reducing UTI risk. E: Keeping the bag below bladder level prevents urine reflux. A: Hand rubs require 15-30 seconds. B: Routine changes increase risk. C: Larger catheters may be needed.
The nurse sees multiple items on the client's bedside table. Which items should the nurse remove because they pose a risk of infection for the client? Select all that apply.
- A. The menu from the client's last meal
- B. A glass of water without a cover
- C. An empty urinal that had been rinsed
- D. A sealed package of soda crackers
- E. A pitcher of water covered with a lid
- F. A bloody alcohol swab from an injection
Correct Answer: B,C,F
Rationale: B: Uncovered water can become contaminated over time. C: A rinsed urinal may still harbor microorganisms. F: A bloody swab is a biohazard and can transmit pathogens. A, D, E are safe as they are either non-contaminable or properly sealed.
An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be
- A. assess the severity and location of the pain
- B. obtain an order for an analgesic
- C. reassure him that this is not unusual for his age
- D. encourage him to increase his activity
Correct Answer: A
Rationale: assess the severity and location of the pain. Most older adults have 1 or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than 'pain') to reveal the presence of pain. There is no evidence that pain of older adults is less intense, and it is necessary for the nurse to assess the pain thoroughly before implementing pain relief measures.
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?
- A. As you urinate more, you will need less medication to control fluid.'
- B. You will have to take this medication for about a year.'
- C. The medication must be continued so the fluid problem is controlled.'
- D. Please talk to your health care provider about medications and treatments.'
Correct Answer: C
Rationale: The medication must be continued so the fluid problem is controlled.' This is the most therapeutic response and gives the client accurate information.