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A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first?
- A. Cleanse the site around the catheter
- B. Use a 20 ml syringe to deflate balloon
- C. Clamp catheter until the client voids naturally
- D. Empty urine from the urinary drainage bag
Correct Answer: B
Rationale: The correct answer is to use a 20 ml syringe to deflate the balloon first when removing a suprapubic catheter. This step is essential to ensure the safe removal of the catheter without causing any harm or discomfort to the client. Deflating the balloon allows for the catheter to be easily removed. Option A, cleansing the site around the catheter, is not the initial step in this process and can be done after catheter removal. Option C, clamping the catheter until the client voids naturally, is incorrect as it can lead to complications like urinary retention. Option D, emptying urine from the urinary drainage bag, is not the first step in removing the suprapubic catheter and does not address the need to deflate the balloon for safe removal.
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The nurse is evaluating a client who has had a mastectomy and is experiencing pain and swelling in the arm on the affected side. What action should the nurse take?
- A. Assess for signs of lymphedema
- B. Encourage the client to perform arm exercises
- C. Provide pain relief through medication
- D. Recommend wearing a compression sleeve
Correct Answer: A
Rationale: Assessing for signs of lymphedema is crucial in this situation as it is a common complication following mastectomy. Lymphedema presents as swelling and pain in the affected arm due to compromised lymphatic drainage. By assessing for lymphedema, the nurse can identify the condition early and implement appropriate interventions such as compression sleeves, manual lymphatic drainage, and exercises. Encouraging arm exercises (Choice B) may exacerbate the symptoms if lymphedema is present. While providing pain relief through medication (Choice C) is important, assessing for the underlying cause of pain and swelling takes precedence. Recommending a compression sleeve (Choice D) may be suitable but should come after a thorough assessment for lymphedema to ensure the most effective management plan.
A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?
- A. Encourage the use of corrective lenses during the day
- B. Practice visual exercises that focus on a still object
- C. Alternate an eye patch from eye every 2 hours
- D. Teach techniques for scanning the environment
Correct Answer: D
Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.
After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?
- A. Ask the client about gastrointestinal pain
- B. Measure the client's fluid intake and output
- C. Monitor the client's serum electrolyte levels
- D. Auscultate for bowel sounds in all quadrants
Correct Answer: A
Rationale: The correct answer is A: Ask the client about gastrointestinal pain. The effectiveness of a proton pump inhibitor (PPI) is best evaluated by assessing the relief of gastrointestinal symptoms, such as heartburn, acid reflux, or stomach pain. These medications work by reducing the production of stomach acid, so improvement in these symptoms indicates the effectiveness of the PPI. Choices B, C, and D are incorrect because they do not directly reflect the effectiveness of a PPI. Measuring fluid intake and output, monitoring serum electrolyte levels, and auscultating for bowel sounds are important for assessing hydration status, electrolyte balance, and gastrointestinal motility, respectively. However, they are not specific to evaluating PPI effectiveness.
A newborn whose mother is HIV positive is admitted to the nursery from labor and delivery. Which action should the nurse implement first?
- A. Initiate treatment with zidovudine (ZDV) syrup at 2 mg per kg
- B. Bathe the infant with dilute chlorhexidine (Hibiclens) or soap
- C. Measure and record the infant's frontal-occipital circumference
- D. Administer vitamin K (AquaMEPHYTON) IM in the vastus lateralis
Correct Answer: B
Rationale: The correct first action for a newborn potentially exposed to HIV is to bathe the infant with dilute chlorhexidine or soap. This helps reduce the risk of infection. Initiating treatment with zidovudine would be important but not the first priority. Measuring and recording the infant's frontal-occipital circumference and administering vitamin K are important tasks but are not the priority when dealing with potential HIV exposure. Immediate hygiene measures are crucial to minimize the risk of transmission.
The client is assessing a client who was recently diagnosed with heart failure and is on a low-sodium diet. Which statement by the client indicates a need for further teaching?
- A. "I will use lemon juice and herbs for flavoring."
- B. "I will not eat canned soups or frozen dinners."
- C. "I can have salt substitutes to enhance the taste of my food."
- D. "I will check the food labels for sodium content before buying."
Correct Answer: C
Rationale: The correct answer is C. Some salt substitutes can be high in potassium, which may not be suitable for clients with heart failure. Option A is correct as using lemon juice and herbs for flavoring is a good low-sodium alternative. Option B is also correct as canned soups and frozen dinners are typically high in sodium content. Option D is correct as checking food labels for sodium content is an essential part of managing a low-sodium diet. Therefore, the client's statement about using salt substitutes needs correction as it can introduce high levels of potassium, which may not be recommended for individuals with heart failure.