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A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
- A. Bleeding gums
- B. Faintness upon rising
- C. Urinary frequency
- D. Swelling of the face
Correct Answer: D
Rationale: The correct answer is D: Swelling of the face. At 14 weeks of gestation, facial swelling could indicate preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This finding should be reported to the provider immediately for further evaluation and management to prevent complications for both the mother and the baby.
Other choices are incorrect because:
A: Bleeding gums are common during pregnancy due to hormonal changes and increased blood flow to the gums.
B: Faintness upon rising may be due to postural hypotension, common in pregnancy.
C: Urinary frequency is a common complaint in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus.
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A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?'
- B. Has anyone in your family committed suicide?'
- C. Is there anyone you would like involved in your care?'
- D. Are you thinking about ending your life?'
Correct Answer: D
Rationale: The correct question to ask first is D: "Are you thinking about ending your life?" This is important to assess the client's risk of suicide, as the statement "It's hard to go on without him" can indicate suicidal ideation. It is crucial to address safety concerns immediately. Asking about coping strategies (A) can come later. Inquiring about family suicide history (B) may not be relevant at this stage. Involving others in care (C) is important but not as urgent as assessing suicidal thoughts.
A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?
- A. Discard the radioactive source in the client's trash can.
- B. Place the client's soiled bed linens in a biohazard bag outside the client's room
- C. Wear an isolation gown when caring for the client
- D. Keep visitors at least 6 feet (1.8 m) away from the client.
Correct Answer: D
Rationale: The correct answer is D: Keep visitors at least 6 feet (1.8 m) away from the client. This is important in brachytherapy as the client is emitting radiation. By keeping visitors at a safe distance, the nurse ensures their safety from radiation exposure. A: Discarding the radioactive source in the trash can is incorrect as it poses a risk to others. B: Placing soiled linens in a biohazard bag is not directly related to radiation safety. C: Wearing an isolation gown does not provide sufficient protection against radiation. Therefore, it is important for the nurse to maintain distance to prevent radiation exposure to visitors.
A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.'
- B. I can visit my nephew who has chickenpox 5 days after the sores have crusted'
- C. I can clean my cat's litter box during my pregnancy.'
- D. I should wash my hands for 10 seconds with hot water after working in the garden.'
Correct Answer: B
Rationale: The correct answer is B: "I can visit my nephew who has chickenpox 5 days after the sores have crusted." This response indicates understanding of infection prevention because chickenpox is contagious until the sores crust over completely, which usually takes about 5-7 days. Visiting the nephew after this period reduces the risk of contracting the virus.
Incorrect options:
A: Taking antibiotics for a virus is ineffective as antibiotics only work against bacterial infections, not viruses.
C: Cleaning a cat's litter box can expose pregnant individuals to toxoplasmosis, a parasitic infection harmful to the fetus.
D: Washing hands for only 10 seconds with hot water is insufficient to effectively remove germs. The CDC recommends washing for at least 20 seconds with soap and water.
A nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?
- A. Perform the cleansing procedure with a fresh swab two times
- B. Pick up the catheter 13 cm (5 in) from its tip
- C. Cleanse the tip of the penis in a side-to-side motion
- D. Lift the penis so that it is perpendicular to the client's body
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps in straightening the urethra, making it easier to insert the catheter. Lifting the penis perpendicular to the body also reduces the risk of trauma or injury during catheterization.
A, B, and C are incorrect because performing the cleansing procedure two times with a fresh swab, picking up the catheter 13 cm from its tip, and cleansing the tip of the penis in a side-to-side motion are not recommended practices and may increase the risk of contamination or injury.
A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take?
- A. Wait 1 day to collect the specimen if the client cannot provide sputum.
- B. Wear sterile gloves to collect the specimen from the client.
- C. Ask the client to provide 15 to 20 mL of sputum into the container
- D. Obtain the specimen immediately upon the client waking up.
Correct Answer: D
Rationale: The correct answer is D: Obtain the specimen immediately upon the client waking up. This is the correct action because sputum is most concentrated in the morning, making it easier to collect a good sample for testing. Waiting 1 day (A) can delay treatment. Wearing sterile gloves (B) is important but not specific to sputum collection. Asking for 15-20mL of sputum (C) is appropriate, but the timing of collection is crucial.