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A nurse is assessing a client who reports pain at the site of an indwelling urinary catheter. What is the nurse's first action?
- A. Irrigate the catheter with normal saline
- B. Notify the provider
- C. Administer prescribed antibiotics
- D. Assess for signs of infection
Correct Answer: B
Rationale: When a client reports pain at the site of an indwelling urinary catheter, the nurse's first action should be to notify the provider. This is important to ensure timely assessment and intervention by the healthcare provider. Irrigating the catheter with normal saline or administering antibiotics should not be done without provider's orders as it may mask symptoms or lead to inappropriate treatment. Assessing for signs of infection is important but should come after notifying the provider, who can guide further assessment and treatment.
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A client has a new prescription for a metered-dose inhaler (MDI). What instruction should the nurse include?
- A. Inhale the medication for 1 second
- B. Shake the inhaler vigorously before use
- C. Hold the inhaler 1-2 inches from the mouth
- D. Exhale immediately after inhalation
Correct Answer: C
Rationale: The correct instruction for a client using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance allows for the proper delivery of the medication into the lungs. Choice A is incorrect because the duration of inhalation can vary depending on the medication, and 1 second may not be adequate. Choice B is incorrect as shaking the inhaler vigorously is not necessary for all MDIs and can lead to inaccurate dosing. Choice D is incorrect as the client should hold their breath for about 10 seconds after inhalation to allow the medication to deposit in the lungs.
A nurse is reviewing a client's health history and identifies chronic constipation as a potential complication of immobility. What intervention should the nurse include in the plan of care?
- A. Increase fiber intake
- B. Encourage the client to walk daily
- C. Use a stool softener as needed
- D. Use a laxative daily
Correct Answer: A
Rationale: Increasing fiber intake is the appropriate intervention to include in the plan of care for a client with chronic constipation due to immobility. Fiber helps add bulk to the stool, making it easier to pass, thereby preventing constipation. Encouraging the client to walk daily (choice B) is also beneficial as it promotes mobility and can help alleviate constipation associated with immobility. Using a stool softener as needed (choice C) and using a laxative daily (choice D) are not the first-line interventions for managing constipation related to immobility. Stool softeners and laxatives should be used judiciously and under healthcare provider guidance.
A nurse is preparing to administer a medication through a nasogastric (NG) tube. What action should the nurse take first?
- A. Flush the NG tube with 60 mL of water
- B. Verify tube placement
- C. Crush the medications and dissolve them in water
- D. Administer all medications together
Correct Answer: B
Rationale: Verifying tube placement is the priority before administering any medications through a nasogastric tube. This step ensures that the tube is correctly positioned in the stomach to prevent complications such as aspiration. Flushing the tube with water, crushing medications, or administering them together should only be done after confirming the correct placement of the NG tube. Therefore, option B is the correct first action to take in this scenario.
A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?
- A. Steamed carrots
- B. Mashed potatoes
- C. Orange slices
- D. Soft-cooked eggs
Correct Answer: C
Rationale: The correct answer is C: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices have membranes that can be challenging to consume for individuals with swallowing difficulties. Steamed carrots (Choice A) and mashed potatoes (Choice B) are typically suitable for a mechanical soft diet as they can be easily mashed or cut into smaller pieces. Soft-cooked eggs (Choice D) are also appropriate for this diet as they are soft and easy to chew.
A healthcare professional is preparing to administer multiple medications to a client with dysphagia. What action should the healthcare professional take?
- A. Offer the medications with a full glass of water
- B. Crush the medications and mix them together
- C. Provide the medications through a straw
- D. Mix the medications with applesauce
Correct Answer: C
Rationale: Clients with dysphagia have difficulty swallowing, so providing medications through a straw can help control the flow and prevent aspiration. Offering medications with a full glass of water (Choice A) may increase the risk of aspiration. Crushing medications and mixing them together (Choice B) can alter the medication's effectiveness or cause adverse effects. Mixing medications with applesauce (Choice D) may also present a choking hazard for clients with dysphagia.