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A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Explain the need to limit intake of oral fluids to reduce client discomfort.
- B. Teach the client techniques for performing intermittent catheterization.
- C. Remind the client to practice pelvic floor (Kegel) exercises regularly.
- D. Provide a bedside commode for immediate use in the client's room.
Correct Answer: B
Rationale: Intermittent catheterization manages urinary retention effectively in multiple sclerosis, maintaining bladder health.
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An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The patient reports feeling very weak and jittery. What actions should the nurse take?
- A. Check fingerstick glucose level.
- B. Assess skin temperature and moisture.
- C. Administer a PRN dose of regular insulin.
- D. Document anxiety on the surgical checklist.
- E. Measure pulse and blood pressure.
Correct Answer: A,B,E
Rationale: Checking fingerstick glucose, assessing skin temperature/moisture, and measuring pulse/blood pressure are critical to evaluate for hypoglycemia, a likely cause of weakness and jitteriness in a diabetic patient.
A nurse is caring for a patient who has been admitted to the hospital with a suspected diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the patient for?
- A. Lumbar puncture.
- B. Skull radiography.
- C. Magnetic resonance imaging (MRI).
- D. Computerized tomography (CT) scan.
Correct Answer: A
Rationale: A lumbar puncture is essential for confirming bacterial meningitis by analyzing cerebrospinal fluid, making it the priority diagnostic procedure.
A patient in the operating room has been administered succinylcholine and is now experiencing muscle rigidity and an extremely high temperature. What should the nurse do next?
- A. Call the PACU nurse to prepare for prolonged ventilatory support.
- B. Hold a prescription for dantrolene until the fever is reduced.
- C. Prepare ice packs for placement in the patient's axillary area.
- D. Determine if prescribed antibiotics were administered preoperatively.
- E. None
- F. None
Correct Answer: C
Rationale: Applying ice packs addresses hyperthermia in malignant hyperthermia, a critical response to succinylcholine-induced symptoms.
A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?
- A. Document the findings.
- B. Elevate the extremity.
- C. Apply gentle pressure.
- D. Assess the client's temperature.
Correct Answer: A
Rationale: A bruit indicates a patent AV graft, a normal finding that should be documented.
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
- A. White blood cell count.
- B. Platelet count.
- C. Red blood cell count.
- D. Hemoglobin levels.
Correct Answer: B
Rationale: Platelet count is critical as low levels cause petechiae and ecchymosis due to bleeding tendencies.