Nokea
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
- A. Neurogenic bladder
- B. Infection
- C. Skin breakdown
- D. Pistolate
Correct Answer: B
Rationale: The correct answer is B: Infection. The kinked IV tubing and the urinary catheter bag lying next to the client in bed can lead to contamination of the catheter system, increasing the risk of a urinary tract infection. The kinked tubing can cause backup of urine, leading to bacterial growth, while the catheter bag being on the bed can introduce pathogens to the catheter. Infections can result in serious complications for the client if not addressed promptly. The other choices, A: Neurogenic bladder, C: Skin breakdown, and D: Pistolate, are not directly related to the scenario presented and do not pose an immediate risk based on the information provided.
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A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Abnormal vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Abnormal vaginal bleeding. This is a possible indication of cervical cancer because it can be a symptom of cervical dysplasia or cervical cancer. Bleeding between periods, after intercourse, or post-menopausal bleeding may indicate cervical cancer. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typically associated with cervical cancer. Diarrhea and urinary hesitancy are more commonly linked to gastrointestinal or urinary issues, while unexplained weight gain may be indicative of hormonal imbalances or other health conditions unrelated to cervical cancer.
A nurse is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
- A. Move client to a double room.
- B. Use chemical restraints at bedtime.
- C. Use a bed alarm.
- D. Encourage participation in activities that provide excessive stimulation.
Correct Answer: C
Rationale: The correct answer is C: Use a bed alarm. This option promotes client safety by alerting the nurse when the client attempts to leave the bed, reducing the risk of wandering. Moving the client to a double room (A) does not address the wandering behavior. Using chemical restraints (B) is unethical and can lead to adverse effects. Encouraging excessive stimulation (D) can escalate agitation and wandering behavior.
A nurse is caring for a client who has cervical cancer and is receiving internal radiation therapy. Which of the following actions should the nurse take?
- A. Check if the radioactive device is in the correct position.
- B. Limit time for visitors to 2 hours per day.
- C. Ask visitors to remain 3 feet from the client.
- D. Keep lead-lined aprons in the client's room.
Correct Answer: A
Rationale: The correct action for the nurse to take is to check if the radioactive device is in the correct position. This is crucial to ensure that the radiation therapy is being delivered accurately and effectively. By verifying the position of the radioactive device, the nurse can prevent potential harm to the client and ensure the success of the treatment.
Choice B is incorrect because limiting visitors' time does not directly relate to the safety and effectiveness of the radiation therapy. Choice C is incorrect as asking visitors to remain 3 feet away does not address the primary concern of verifying the device's position. Choice D is also incorrect as lead-lined aprons are typically used by healthcare providers during procedures, not by the client.
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
- A. Distended jugular veins
- B. Increased blood pressure
- C. Decreased blood pressure
- D. Pitting, dependent edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure. Dehydration in a client with gastroenteritis results in a decrease in blood volume, leading to decreased blood pressure. When the body loses fluids through vomiting and diarrhea, there is a reduction in circulating blood volume, causing a drop in blood pressure. This can result in symptoms such as dizziness, weakness, and increased heart rate as the body tries to compensate for the reduced blood volume. Distended jugular veins (A) are more indicative of heart failure, increased blood pressure (B) can occur in conditions like hypertension or stress, and pitting, dependent edema (D) is a sign of fluid overload, not dehydration.
A nurse is continuing to care for a client who is postoperative following surgical removal of an abdominal abscess. Which of the following actions should the nurse take?
- A. Obtain vital signs every 30 minutes.
- B. Elevate the client in a semi-Fowler's position.
- C. Apply oxygen.
- D. Monitor the client's level of consciousness.
Correct Answer: B
Rationale: The correct answer is B: Elevate the client in a semi-Fowler's position. Elevating the client in a semi-Fowler's position helps promote optimal lung expansion and ventilation, reducing the risk of postoperative complications such as atelectasis and pneumonia. This position also aids in preventing aspiration and promotes comfort.
Choice A: Obtaining vital signs every 30 minutes is important postoperatively, but it is not the most immediate action needed in this case.
Choice C: Applying oxygen may be necessary depending on the client's oxygen saturation levels, but it is not the most essential action to take at this point.
Choice D: Monitoring the client's level of consciousness is important, but it is not as critical as positioning the client correctly to prevent respiratory complications.