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A nurse is caring for a client who has not voided for 8 hr following surgery. Which of the following actions should the nurse take first?
- A. Offer the client fluids.
- B. Perform a bladder scan.
- C. Insert an indwelling urinary catheter.
- D. Provide assistance to bathroom.
Correct Answer: B
Rationale: The correct answer is B: Perform a bladder scan. This is the first action the nurse should take because it provides valuable information about the client's bladder status without invasive intervention. The bladder scan will help determine if the client has urinary retention, which could be the reason for not voiding after surgery. Offering fluids (choice A) is important but should come after assessing the bladder. Inserting a urinary catheter (choice C) is invasive and should only be done if necessary. Providing assistance to the bathroom (choice D) is not appropriate if there is a possibility of urinary retention.
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A nurse is caring for a client who has a respiratory infection. When the client asks how the position the nurse put him in can help, the nurse should explain that lying on his left side in Trendelenburg position helps mobilize secretions from which of the following lung segments?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the left upper lobe
- D. Posterior segment of the right lower lobe
Correct Answer: A
Rationale: Postural drainage uses gravity to mobilize mucus from different lung segments, aiding in secretion clearance.
A nurse is measuring an adult client's tympanic temperature. Which of the following actions should the nurse take?
- A. Use a cotton-tipped applicator to remove cerumen.
- B. Pull the pinna downward and backward.
- C. Aim the probe posteriorly in the direction of the eardrum.
- D. Insert the probe with a circular motion.
Correct Answer: C
Rationale: The correct answer is C because aiming the probe posteriorly in the direction of the eardrum allows for accurate tympanic temperature measurement. This ensures that the infrared sensor is positioned correctly to capture the heat emitted from the tympanic membrane. Choice A is incorrect as removing cerumen is not necessary for temperature measurement. Choice B is incorrect as pulling the pinna downward and backward is not required for tympanic temperature measurement. Choice D is incorrect as inserting the probe with a circular motion may cause discomfort or injury to the ear canal.
A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous low-pitched gurgling sounds heard over the trachea and bronchi. These sounds are typically caused by the movement of air through narrowed airways due to secretions or inflammation. Crackles (B) are discontinuous, popping sounds typically heard during inspiration and caused by fluid in the alveoli. Wheezing (C) is a high-pitched musical sound heard on expiration and caused by narrowed airways. Friction rub (D) is a grating, rubbing sound heard during inspiration and expiration and is typically associated with inflammation of the pleura.
A nurse is caring for a client who practices Orthodox Judaism. The nurse should identify that which of the following foods together on the same dinner tray violates the client's religious practices?
- A. Kosher roast beef and ice cream
- B. Carrot sticks and cottage cheese
- C. Macaroni and cheese
- D. Kosher chicken breast and boiled potatoes
Correct Answer: A
Rationale: The correct answer is A: Kosher roast beef and ice cream. In Orthodox Judaism, meat and dairy products cannot be consumed together. Kosher laws prohibit mixing meat and dairy in the same meal or on the same plate to maintain dietary restrictions. Choices B, C, and D do not violate this rule as they do not mix meat and dairy products. Carrot sticks and cottage cheese (B), macaroni and cheese (C), and kosher chicken breast and boiled potatoes (D) are all permissible combinations in Orthodox Judaism.
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse use as a primary source of accurate data about the client?
- A. Client concerns
- B. Family information
- C. Medical history
- D. Progress notes
Correct Answer: A
Rationale: The correct answer is A: Client concerns. The primary source of accurate data about the client should always be the client themselves. Clients are the most reliable sources of information regarding their own health, symptoms, and preferences. By directly asking the client about their concerns, the nurse can gather accurate and firsthand information. Family information (B) may be helpful but may not always be completely accurate. Medical history (C) and progress notes (D) are important sources of information but may not always reflect the client's current status or concerns. It is crucial to prioritize the client's perspective to ensure personalized and effective care.