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A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?
- A. Severe wheezing
- B. Rhinitis
- C. Small, raised vesicles over the body
- D. Itching of the skin
Correct Answer: A
Rationale: Severe wheezing suggests anaphylaxis, a life-threatening reaction requiring immediate intervention.
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A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Prepare a dry work surface above the waist level.
- B. Open the outside cover of the sterile kit and remove the dust cover.
- C. Grasp the outermost flap of the sterile kit while opening away from the body.
- D. Open each side flap of the sterile kit individually while pulling to the side.
- E. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
Correct Answer: A,B,C,D,E
Rationale: This sequence (A,B,C,D,E) maintains sterility by preparing, opening away, and avoiding contamination.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Use overhead lighting when checking equipment.
- B. Keep the door to the client's room closed.
- C. Provide the client with snug-fitting nightwear.
- D. Administer prescribed diuretics in the evening.
Correct Answer: B
Rationale: Closing the door reduces noise, promoting a sleep-conducive environment.
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client has poorly fitting dentures.
- B. The client verbalizes regret about never marrying.
- C. The client is sedentary throughout most of the day.
- D. The client has no living family.
Correct Answer: C
Rationale: Sedentary behavior heightens risks like DVT and cardiovascular issues, making it the priority.
A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has rubella
- B. A client who has tuberculosis
- C. A client who is HIV-positive
- D. A client who has had varicella
Correct Answer: D
Rationale: Prior varicella exposure prevents shingles transmission, making this roommate safe.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Inflate the catheter's balloon.
- B. Lower the penis to a 45° angle.
- C. Apply lidocaine gel to the urethra.
- D. Twist the catheter gently.
Correct Answer: D
Rationale: Gentle twisting can navigate urethral obstructions safely without causing trauma.