Nokea
A client has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?
- A. Bladder scan shows 525 mL of urine
- B. Urine has a strong odor
- C. The client reports abdominal discomfort
- D. The catheter is blocked or not draining
Correct Answer: D
Rationale: The correct answer is D because if the catheter is blocked or not draining, it may need irrigation to restore proper flow. Option A, 'Bladder scan shows 525 mL of urine,' does not necessarily indicate the need for irrigation as it could be within the expected range for catheter drainage. Option B, 'Urine has a strong odor,' may indicate a urinary tract infection but does not directly correlate with the need for catheter irrigation. Option C, 'The client reports abdominal discomfort,' could indicate various issues but does not specifically suggest the need for catheter irrigation.
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The nurse is preparing to administer a subcutaneous injection of insulin to a client with diabetes. What is the best site for the nurse to select for this injection?
- A. Ventrogluteal site
- B. Dorsogluteal site
- C. Deltoid site
- D. Abdomen
Correct Answer: D
Rationale: The correct answer is 'D: Abdomen.' The abdomen is the best site for insulin injections as it provides a larger area with consistent absorption rates due to the high vascularity of the area. The subcutaneous tissue in the abdomen allows for a more predictable and consistent absorption of insulin compared to other sites. Ventrogluteal and dorsogluteal sites are not commonly used for insulin injections due to the risk of hitting the sciatic nerve or causing tissue damage. The deltoid site is more commonly used for intramuscular injections rather than subcutaneous injections like insulin.
The patient is being treated for cancer with weekly radiation therapy to the head and intravenous chemotherapy treatments. Which assessment is the priority?
- A. Feet
- B. Nail beds
- C. Perineum
- D. Oral cavity
Correct Answer: D
Rationale: The correct answer is the oral cavity. During cancer treatment involving radiation to the head and intravenous chemotherapy, the oral cavity is a priority assessment area. Radiation can reduce salivary flow and lower the pH of saliva, which can lead to stomatitis and tooth decay. Assessing the oral cavity allows for the early identification and management of potential complications.
Choice A, assessing the feet, is not the priority in this scenario as it is not directly impacted by the described cancer treatments.
Choice B, assessing the nail beds, is not the priority compared to the oral cavity. Nail bed assessment may be relevant for certain conditions, but in this case, the oral cavity is of higher priority due to the specific treatment effects.
Choice C, assessing the perineum, is also not the priority in this situation as it is not directly affected by the described cancer treatments, unlike the oral cavity.
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
- A. A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
- B. The nurse avoids discussing the client's diagnosis to prevent emotional distress.
- C. The nurse provides a vague answer about the client's condition.
- D. The nurse promises to provide information only if it is requested by the client.
Correct Answer: A
Rationale: Veracity involves telling the truth, a fundamental ethical principle in healthcare. In this scenario, the nurse demonstrates veracity by responding honestly when the client directly asks about her cancer diagnosis. Choice B is incorrect as avoiding discussing the diagnosis to prevent emotional distress does not align with veracity and transparency. Choice C is incorrect as providing a vague answer does not uphold the principle of truthfulness. Choice D is incorrect because promising to provide information only upon client request does not address the immediate question about the cancer diagnosis and lacks transparency.
When a nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client, what should be the next action by the nurse?
- A. Discuss the feeling of reluctance with an objective peer or supervisor
- B. Limit contact with the client to avoid reinforcement of the manipulative behavior
- C. Confront the client about the negative effects of behaviors on other clients and staff
- D. Develop a behavior modification plan that will promote more functional behavior
Correct Answer: A
Rationale: The correct action for the nurse in this situation is to discuss the feeling of reluctance with an objective peer or supervisor. By doing so, the nurse can address their emotions professionally and seek guidance on how to manage the situation effectively. This approach allows the nurse to receive support and potentially gain insights on how to navigate interactions with the manipulative client. Option B is incorrect because avoiding the client may not address the underlying issues causing the reluctance and can impact the quality of care provided. Option C is inappropriate as confronting the client directly about negative behaviors may escalate the situation and harm the therapeutic relationship. Option D is not the immediate action needed in this scenario; it is essential to address the nurse's feelings first before considering behavior modification plans.
The healthcare professional is preparing to administer a medication through a nasogastric (NG) tube. Which action should the healthcare professional take to ensure proper administration?
- A. Flush the tube with 30 ml of water before and after medication administration.
- B. Administer the medication with food to prevent nausea.
- C. Verify tube placement by aspirating stomach contents.
- D. Dilute the medication with normal saline before administration.
Correct Answer: A
Rationale: Flushing the NG tube with water before and after medication administration is essential to ensure the tube is patent and prevent clogging. This action helps in clearing the tube and ensures that the medication is delivered properly. Administering medication with food (Choice B) may not be appropriate for all medications and can interfere with their absorption. Verifying tube placement by aspirating stomach contents (Choice C) is important but does not directly relate to ensuring proper medication administration. Diluting the medication with normal saline (Choice D) is not a standard practice for administering medications through an NG tube.