Nokea
A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?
- A. Check the urethral catheter and drainage tubing
- B. Irrigate the catheter with 30 mL sterile normal saline
- C. Notify the registered nurse
- D. Remove and reinsert the next larger size catheter
Correct Answer: A
Rationale: Checking the catheter and tubing first ensures there are no kinks, blockages, or improper placements causing the leak, which is a non-invasive and logical initial step. Irrigation or removal requires further assessment, and notifying the RN is premature without initial troubleshooting.
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The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize
- A. The need for at least 5 servings of dairy products daily
- B. Restriction of fluid intake to less than 1 liter per day
- C. The importance of walking as much as possible
- D. The use of sunscreen to prevent skin damage
Correct Answer: C
Rationale: The importance of walking as much as possible. Mobility prevents bone demineralization, reducing the risk of hypercalcemia.
The nurse is caring for a client admitted with a sickle cell crisis. What assessment finding is not consistent with the diagnosis?
- A. Enlarged liver and spleen
- B. Jaundice and icterus
- C. Decreased white blood cell count
- D. Abdominal and joint pain
Correct Answer: C
Rationale: Sickle cell crisis typically causes elevated white blood cell counts due to inflammation or infection. Hepatomegaly, jaundice, and pain are consistent findings.
A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: 'The manager makes all decisions and rarely asks for our input.' The best description of the nurse manager's management style is
- A. Participative or democratic
- B. Ultraliberal or communicative
- C. Autocratic or authoritarian
- D. Laissez faire or permissive
Correct Answer: C
Rationale: Autocratic or authoritarian. The manager’s decision-making without staff input indicates an autocratic leadership style.
A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the nurse expect to administer in addition to the scheduled vaccines?
- A. pneumococcal vaccine
- B. hepatitis A vaccine
- C. Lyme disease vaccine
- D. typhoid vaccine
Correct Answer: A
Rationale: Children with HIV require pneumococcal vaccine to protect against opportunistic infections due to immunocompromise. The other vaccines are not routinely indicated for HIV. Health Promotion and Maintenance
A chemical reaction between drugs prior to their administration or absorption is known as:
- A. a drug incompatibility.
- B. a side effect.
- C. an adverse event.
- D. an allergic response.
Correct Answer: A
Rationale: Drug incompatibility refers to chemical reactions between drugs before administration, like precipitation in IV lines. Side effects, adverse events, and allergic responses occur post-administration. Pharmacological Therapies