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A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?
- A. Bladder distention
- B. Frequent urination
- C. Dark urine
- D. Increased thirst
Correct Answer: A
Rationale: Bladder distention indicates the inability to empty the bladder, which can be a sign of catheter occlusion.
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A nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery. Which of the following statements should the nurse make?
- A. You should not worry about it
- B. The surgeon will answer your questions before surgery
- C. It's too late to cancel the surgery
- D. You need to trust the medical team
Correct Answer: B
Rationale: The nurse should encourage the client to express concerns and ensure that the surgeon addresses any questions prior to the procedure.
A nurse is updating a plan of care after evaluating a client who has dysphagia. Which interventions should the nurse include in the plan?
- A. Have the client lie down after meals
- B. Encourage the client to speak while eating
- C. Have the client sit upright for 1 hour following meals
- D. Offer thin liquids with meals
Correct Answer: C
Rationale: Having the client sit upright for 1 hour after meals facilitates swallowing and reduces the risk of aspiration.
A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which of the following client information should the nurse identify as a contributing factor?
- A. The client has a history of recurring bowel inflammation
- B. The client has recently increased their exercise regimen
- C. The client is taking herbal supplements
- D. The client is experiencing increased stress
Correct Answer: A
Rationale: Recurring bowel inflammation can decrease gastrointestinal motility, affecting the absorption of oral medications.
A nurse is caring for a patient who is scheduled for cataract surgery. The client states, "I see just fine and have decided to cancel my surgery." Which of the following responses should the nurse make?
- A. That's not a good idea; the surgery is necessary
- B. Share with me more about the thoughts that are concerning you
- C. You should trust your doctor's advice
- D. You can always reschedule the surgery later
Correct Answer: B
Rationale: Encouraging the client to share their thoughts helps the nurse understand the client's concerns and facilitates a supportive discussion.
A nurse is admitting a client who has meningococcal meningitis. What should the nurse do first?
- A. Initiate droplet precautions
- B. Start intravenous antibiotics
- C. Perform a complete assessment
- D. Notify the healthcare provider
Correct Answer: A
Rationale: Initiating droplet precautions is crucial to prevent the spread of infection, especially in cases of meningococcal meningitis.