Nokea
A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?
- A. Instruct the client to hold the drainage bag at waist height when ambulating.
- B. Coil the tubing on the bed above the collection bag.
- C. Collect a sterile specimen from the urinary drainage bag.
- D. Secure the tubing with adhesive tape to the lower abdomen.
Correct Answer: D
Rationale: Securing the tubing with adhesive tape to the lower abdomen is correct. For male clients, securing the catheter to the lower abdomen prevents urethral trauma and tension. For female clients, the catheter is typically secured to the inner thigh to minimize movement and irritation.
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A nurse is caring for a client who has a new prescription for lamotrigine. Which of the following adverse effects should the nurse monitor for?
- A. Skin rash
- B. Weight gain
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Lamotrigine, an anticonvulsant, can cause a skin rash, which may indicate a serious reaction like Stevens-Johnson syndrome.
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
- A. Anaphylactic
- B. Acute hemolytic
- C. Febrile
- D. Circulatory overload
Correct Answer: A
Rationale: An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.
A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?
- A. Turn on overhead lights briefly when checking IV lines.
- B. Open curtains between clients in semiprivate rooms.
- C. Wear shoes with rubber soles.
- D. Conduct change-of-shift report near the clients' rooms.
Correct Answer: C
Rationale: Wearing shoes with rubber soles is correct. Rubber-soled shoes reduce noise from footsteps, minimizing disturbances in client rooms and creating a quieter environment that promotes sleep.
A nurse is reinforcing teaching with a client who has a new prescription for an albuterol inhaler. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will shake the inhaler before each use.
- B. I will use the inhaler every 2 hours.
- C. I will hold my breath for 5 seconds after inhaling.
- D. I will clean the inhaler with soap and water daily.
Correct Answer: A
Rationale: Shaking the inhaler before each use ensures the medication is properly mixed for effective delivery.
A nurse is caring for a client who has a new diagnosis of shingles. Which of the following findings should the nurse expect?
- A. Painful rash
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: A painful rash, often unilateral and following a dermatomal pattern, is a hallmark symptom of shingles.