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A client has just returned from surgery with an indwelling urinary catheter in place. What is the most important action for the nurse to take to prevent infection?
- A. Change the catheter every 72 hours.
- B. Ensure the catheter tubing is free of kinks.
- C. Clean the perineal area with antiseptic solution daily.
- D. Irrigate the catheter with normal saline every shift.
Correct Answer: B
Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. Kinks in the tubing can lead to urine retention or obstruction, increasing the risk of infection. Changing the catheter every 72 hours is not necessary if there are no signs of infection or other issues. Cleaning the perineal area with antiseptic solution daily is important for hygiene but not the most critical action to prevent infection related to the catheter. Irrigating the catheter with normal saline every shift is not a routine practice and may increase the risk of introducing pathogens into the urinary system.
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A client is admitted with acute pyelonephritis. Which symptom should the nurse expect the client to report?
- A. Flank pain
- B. Pedal edema
- C. Hypotension
- D. Weight gain
Correct Answer: A
Rationale: Flank pain is a classic symptom of acute pyelonephritis, which is a bacterial infection of the kidney. It occurs due to inflammation and irritation of the renal capsule, leading to pain in the flank region. Pedal edema (swelling in the feet and ankles) is more commonly associated with conditions like heart failure or kidney disease, not typically seen in acute pyelonephritis. Hypotension (low blood pressure) is a systemic symptom that may occur with severe infections but is not a specific hallmark of pyelonephritis. Weight gain is also not a typical symptom of acute pyelonephritis; instead, patients may experience weight loss due to decreased appetite and systemic effects of infection.
A client reports constipation, and a nurse is providing dietary teaching. Which of the following foods should the nurse recommend?
- A. Macaroni and cheese
- B. One medium apple with skin
- C. One cup of plain yogurt
- D. Roast chicken and white rice
Correct Answer: B
Rationale: The correct answer is B: One medium apple with skin. Foods high in fiber, like apples with skin, are recommended to relieve constipation due to their fiber content, which aids in bowel regularity. Macaroni and cheese, yogurt, and roast chicken with white rice do not provide as much fiber and are less effective in alleviating constipation. While yogurt can sometimes contain probiotics that support gut health, it is not as effective in treating constipation as high-fiber foods like apples.
When planning home care for a 72-year-old client with osteomyelitis requiring a 6-week course of intravenous antibiotics, what is the most important action by the nurse?
- A. Investigating the client's insurance coverage for home IV antibiotic therapy
- B. Determining if there are adequate hand washing facilities in the home
- C. Assessing the client's ability to participate in self-care and/or the reliability of a caregiver
- D. Selecting the appropriate venous access device
Correct Answer: C
Rationale: Assessing the client's ability to participate in self-care or evaluating the reliability of a caregiver is crucial in ensuring adherence to the treatment plan. This action helps determine if the client can manage the intravenous antibiotics at home independently or if assistance is needed. Investigating insurance coverage, ensuring hand washing facilities, and selecting the venous access device are important aspects of care but assessing the client's ability for self-care and caregiver reliability takes precedence to promote treatment success and safety.
A healthcare provider is providing teaching about health promotion guidelines to a group of young adult male clients. Which of the following guidelines should the healthcare provider include?
- A. Obtain a tetanus booster every 5 years.
- B. Obtain a herpes zoster immunization by age 50.
- C. Have a dental examination every 6 months.
- D. Have a testicular examination every 2 years.
Correct Answer: C
Rationale: Having a dental examination every 6 months is crucial for young adult males as it helps in maintaining good oral health and detecting any potential issues early on. Tetanus booster every 10 years is recommended for adults, not every 5 years (Choice A). Herpes zoster immunization is typically recommended for individuals aged 60 and older, not by age 50 (Choice B). While testicular self-examination is important for detecting testicular cancer, routine clinical testicular examinations are not generally needed every 2 years (Choice D). Therefore, the correct answer is to have a dental examination every 6 months.
During the physical assessment of a client, which technique should a nurse use when performing a Romberg's test?
- A. Touch the client's face with a cotton ball
- B. Apply a vibrating tuning fork to the client's forehead
- C. Have the client stand with arms at her sides and feet together
- D. Perform direct percussion over the area of the kidneys
Correct Answer: C
Rationale: During a Romberg's test, the nurse assesses the client's balance. Having the client stand with arms at her sides and feet together is the correct technique. This position helps the nurse observe for swaying or loss of balance, indicating alterations in balance. Choices A and B are incorrect as they are not part of Romberg's test and do not assess balance. Choice D is also incorrect as direct percussion over the kidneys is not associated with a Romberg's test.