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A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the specimen in a clean specimen cup.
- B. Clamp the catheter tubing below the needleless port.
- C. Clamp the catheter tubing for 60 min.
- D. Remove 45 mL of urine from the catheter with a syringe.
Correct Answer: B
Rationale: Clamping below the port allows fresh urine to collect for an accurate culture.
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Nurses' Notes
Diagnostic Results
Day 1:
1000:
A peripherally inserted central catheter (PICC) is inserted into left arm. Dressing dry and intact. Bilateral breath sounds clear and present throughout.
1200:
Parenteral nutrition started through PICC line infusing at 75 mL/hr.
Day 3:
0800:
Client is lethargic and reports thirst and frequent urination. Bilateral breath sounds clear and present throughout.
A nurse is reviewing the medical record of a client who has a paralytic ileus.
Select words from the choices below to fill in each blank in the following sentence:
The findings in the client's medical record indicate----and----.
- A. Dehydration
- B. Pneumothorax
- C. Hyperglycemia
- D. Infection
- E. Electrolyte Imbalance
- F. Hypoglycemia
Correct Answer: A, C
Rationale: A: Thirst and urination suggest dehydration. C: Lethargy and polyuria indicate hyperglycemia from parenteral nutrition.
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 verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: D
Rationale: Sedentary lifestyle is a priority as it poses immediate health risks like thrombosis or muscle atrophy.
A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clean around the stoma with a moisturizing soap.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will cut an opening in the skin barrier that is 1/2 inch larger than the stoma.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the barrier ensures a secure seal, preventing leaks.
Provider’s Prescriptions
Nurses' Notes
Medical History
Day 1, 1030:
Amoxicillin 500 mg PO every 8 hr Metoprolol 50 mg PO daily
Urine culture and sensitivity
Day 3, 1700:
Metronidazole 250 mg PO three times daily
Obtain stool culture and sensitivity to test for Clostridium difficile.
A nurse is assisting in the care of a client who has a urinary tract infection.
The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.
- A. Recommend increasing the dose of metoprolol
- B. Clarify the prescription for amoxicillin with the provider.
- C. Ensure the client wears a surgical mask when they are outside their room.
- D. Request a prescription for an antiemetic medication
- E. Place the client on contact precautions.
Correct Answer: B, D
Rationale: B: The nurse should clarify the amoxicillin prescription if there's any ambiguity in dosage or administration. D: An antiemetic may be needed if the client experiences nausea from antibiotics or infection.
A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Take a 1-hour nap each day.
- B. Drink a glass of milk before bedtime.
- C. Take a long walk before bedtime.
- D. Watch television in bed.
Correct Answer: B
Rationale: Milk contains tryptophan, which promotes sleep.