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A nurse is caring for a client who has an indwelling urinary catheter. What finding indicates a catheter occlusion?
- A. Bladder distention
- B. Bladder spasms
- C. Hematuria
- D. Increased urine output
Correct Answer: A
Rationale: Bladder distention is the correct finding that indicates a catheter occlusion. When the catheter is occluded, urine cannot drain properly, leading to the build-up of urine in the bladder, causing distention. Bladder spasms (Choice B) are not typically associated with catheter occlusion but may indicate irritation or infection. Hematuria (Choice C) refers to blood in the urine and is not specific to catheter occlusion. Increased urine output (Choice D) is not indicative of catheter occlusion but may suggest other conditions like diabetes insipidus.
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A nurse is assessing a client who reports pain and redness at the site of a peripheral IV. What should the nurse do first?
- A. Apply a cold compress to the site
- B. Discontinue the IV line
- C. Notify the provider
- D. Increase the IV flow rate
Correct Answer: B
Rationale: When a client reports pain and redness at the site of a peripheral IV, indicating signs of phlebitis, the nurse's initial action should be to discontinue the IV line. This helps prevent further complications and ensures patient safety. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider (Choice C) is important but not the initial step. Increasing the IV flow rate (Choice D) can exacerbate the inflammation and should be avoided.
A nurse is caring for a client who is receiving continuous enteral feedings. What finding indicates intolerance to the feeding?
- A. Weight gain
- B. Nausea
- C. Constipation
- D. Elevated heart rate
Correct Answer: B
Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Weight gain is not typically associated with intolerance to enteral feedings; instead, it may indicate other issues such as fluid retention. Constipation is also not a direct indicator of intolerance to enteral feedings. While an elevated heart rate can occur for various reasons, it is less specific to enteral feeding intolerance compared to nausea.
A nurse is preparing to perform a routine abdominal assessment. Which action should the nurse take first?
- A. Percuss the abdomen
- B. Auscultate bowel sounds
- C. Inspect the abdomen
- D. Palpate the abdomen
Correct Answer: B
Rationale: The correct answer is to auscultate bowel sounds. Auscultation should be performed before palpation during an abdominal assessment to avoid altering bowel sounds. Inspecting the abdomen is important but should follow auscultation. Percussion and palpation should be done after auscultation and inspection to ensure an accurate assessment.
A nurse is updating a plan of care for a client who has dysphagia. What intervention should the nurse include?
- A. Encourage the client to lie down after eating
- B. Offer the client liquids with meals
- C. Have the client sit upright for 1 hour after meals
- D. Provide the client with a straw for drinking
Correct Answer: C
Rationale: The correct intervention for a client with dysphagia is to have them sit upright for 1 hour after meals. This position helps facilitate swallowing and reduces the risk of aspiration, which is crucial in managing dysphagia. Encouraging the client to lie down after eating (Choice A) can increase the risk of aspiration. Offering liquids with meals (Choice B) may also increase the risk of aspiration as it can affect swallowing coordination. Providing the client with a straw for drinking (Choice D) is not recommended as straws can increase the risk of aspiration in individuals with dysphagia.
A client signed an informed consent form for surgery but has expressed doubts about the need for surgery. What should the nurse say?
- A. Reassure the client of the surgeon's skill
- B. The surgeon will answer your questions before surgery
- C. Tell the client surgery is necessary
- D. Encourage the client to seek a second opinion
Correct Answer: B
Rationale: The correct answer is B because the surgeon should address the client's doubts before surgery. Informed consent requires that the client fully understands the procedure. Choice A is incorrect because reassuring the client of the surgeon's skill does not address the client's doubts about the need for surgery. Choice C is incorrect because telling the client surgery is necessary may not address their concerns and could violate the principle of autonomy. Choice D is incorrect as the immediate concern is addressing the client's doubts before surgery, not necessarily seeking a second opinion.