Nokea
A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, 'Oh dear, I feel like I have to urinate again!' Which of the following is the most appropriate initial nursing response?
- A. Assure her that this is most likely the result of bladder spasms.
- B. Check the collection bag and tubing to verify that the catheter is draining properly.
- C. Instruct her to do Kegel exercises to diminish the urge to void.
- D. Ask her if she has felt this way before.
Correct Answer: B
Rationale: The most frequent reason for an urge to void with an indwelling catheter is blocked tubing, so checking the catheter's patency is the best initial response.
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The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
- A. Provide manual traction above and below the leg.
- B. Cover the bone area with a sterile dressing.
- C. Apply an ACE bandage around the entire lower limb.
- D. Place the client in the prone position.
Correct Answer: B
Rationale: Covering an open fracture with a sterile dressing prevents infection, a priority. Traction (A) is secondary, an ACE bandage (C) may contaminate the wound, and prone positioning (D) is inappropriate.
A client with a history of a heart transplant is receiving Cyclosporine (Sandimmune). The nurse should monitor the client for:
- A. Infection
- B. Hypotension
- C. Hyperkalemia
- D. Weight loss
Correct Answer: A
Rationale: Cyclosporine suppresses immunity, increasing infection risk, requiring vigilant monitoring. Hypotension, hyperkalemia, and weight loss are less common.
A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
- A. The parts of a system are only minimally related.
- B. Dysfunction in one part affects every other part.
- C. A family system has no boundaries.
- D. Healthy families are enmeshed.
Correct Answer: B
Rationale: Any change in any part of the system affects all other parts.
A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurse's discharge teaching should include:
- A. Telling the client's wife not to touch the tablets
- B. Explaining that the medication should be taken with meals
- C. Telling the client that symptoms will improve in 1-2 weeks
- D. Instructing the client to take the medication at bedtime, to prevent nocturia
Correct Answer: A
Rationale: Finasteride tablets should not be handled by pregnant women due to the risk of fetal harm. Symptom improvement takes months, not weeks, and the medication can be taken with or without food or at any time.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: Nosebleeds in preeclampsia may indicate severe hypertension or coagulopathy, requiring immediate reporting. Pedal edema is common, bed rest is not always needed, and sodium restriction is secondary.