Nokea
A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?
- A. Provide the client with a high fiber diet.
- B. Administer a soap-suds enema to cleanse the colon.
- C. Allow the perineal area to air dry after each stool.
- D. Apply an alcohol-free barrier to the perineal area after each stool.
Correct Answer: D
Rationale: An alcohol-free barrier protects the skin from irritation due to frequent stooling.
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A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?
- A. Chlorhexidine washes
- B. Urinary catheterization
- C. Malnutrition
- D. Multiple caregivers
Correct Answer: B
Rationale: The correct answer is B: Urinary catheterization. This is a common cause of HAIs due to the introduction of bacteria into the urinary tract. Catheters provide a direct pathway for bacteria to enter the body, leading to infections such as urinary tract infections. The other choices are incorrect because:
A: Chlorhexidine washes are actually used to prevent infections by killing bacteria on the skin.
C: Malnutrition can weaken the immune system and make individuals more susceptible to infections, but it is not a direct cause of HAIs.
D: Multiple caregivers can increase the risk of infections if proper hygiene practices are not followed, but it is not a specific cause of HAIs like urinary catheterization.
A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?
- A. High BP and low pulse rate
- B. Low BP and low pulse rate
- C. High BP and high pulse rate
- D. Low BP and high pulse rate
Correct Answer: D
Rationale: Hypovolemic shock leads to decreased blood pressure due to fluid loss and compensatory tachycardia.
A nurse is reinforcing teaching with a client who has a respiratory infection. The nurse should have the client lie on his left side with pillows elevating the right side of his chest to help 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 upper lobe
Correct Answer: D
Rationale: Positioning helps mobilize secretions from specific lung segments, aiding in pulmonary hygiene.
A charge nurse is assisting a newly-licensed nurse to insert an indwelling urinary catheter for a male client. Which of the following actions requires the charge nurse to intervene?
- A. Lubricates the first 2.5 to 5 cm (1 to 2 in) of the catheter tubing
- B. Lubricates the first 15 to 17.5 cm (6 to 7 in) of the catheter
- C. Secures the tubing to the client's upper thigh
- D. Secures the tubing to the client's lower abdomen.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The correct action for inserting an indwelling urinary catheter in a male client is to lubricate the first 15 to 17.5 cm (6 to 7 in) of the catheter, not just the first 2.5 to 5 cm (1 to 2 in). This is crucial to ensure smooth insertion and prevent trauma to the urethra. Therefore, the charge nurse should intervene and guide the newly-licensed nurse to lubricate the appropriate length of the catheter tubing.
Summary of Incorrect Choices:
B: Lubricating the first 15 to 17.5 cm (6 to 7 in) of the catheter is the correct action, not an intervention.
C: Securing the tubing to the client's upper thigh is a proper step to prevent pulling on the catheter, not requiring intervention.
D: Securing the tubing to the client's lower abdomen is also a standard practice to prevent dislod
A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
- A. Excessive laxative use
- B. Ignoring the urge to defecate
- C. Inadequate fluid intake
- D. Increased fiber in the diet
- E. Increased activity
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. A: Excessive laxative use can lead to constipation by causing dependency on laxatives. B: Ignoring the urge to defecate can disrupt the normal bowel movement pattern, leading to constipation. C: Inadequate fluid intake can result in hard, dry stools that are difficult to pass, causing constipation. D: Increased fiber in the diet actually helps prevent constipation by adding bulk to the stool. E: Increased activity generally promotes bowel regularity and helps prevent constipation. By discussing A, B, and C with the client, the nurse can address common causes of constipation and provide appropriate interventions.