Nokea
A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?
- A. Wear loose-fitting underwear.
- B. Take a bubble bath after intercourse.
- C. Drink four 240 mL(8 oz) glasses of water each day.
- D. Void every 5 to 6 hr during the day.
Correct Answer: A
Rationale: The correct answer is A: Wear loose-fitting underwear. Tight clothing can trap moisture and bacteria, leading to UTIs. Loose-fitting underwear allows for better air circulation, reducing the risk of infection. Choice B is incorrect as bubble baths can irritate the urinary tract. Choice C is important for hydration but not directly related to preventing UTIs. Choice D is good practice for bladder health but does not specifically address UTI prevention.
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Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require follow-up.
- A. Smoking marijuana to clear their mind
- B. Attends school regularly
- C. Heart rate 99/min
- D. Client experiences nightmares
- E. BP 122/80 mm Hg
- F. Caregiver reporting client acting differently than usual
- G. Witnessing their family's death
Correct Answer: A,D,F,G
Rationale: These findings suggest unresolved trauma and substance use, requiring intervention.
Which of the following findings places the client at risk if he receives alteplase?
- A. Family history of malignant hypertension
- B. Hip arthroplasty 1 week ago
- C. Chronic obstructive pulmonary disease
- D. Acute renal failure 6 months ago
Correct Answer: B
Rationale: Recent surgeries increase bleeding risks with thrombolytics.
Which of the following responses should the nurse make?
- A. It is always difficult caring for someone who is terminally ill.
- B. You should consider taking a sleeping pill before bed each night.
- C. I can give you information about respite care if you are interested.
- D. I am sure you're doing a great job taking care of your mother.
Correct Answer: C
Rationale: Respite care provides temporary relief for caregivers, which can improve their well-being.
Which of the following instructions should the nurse include in the teaching?
- A. Apply cold packs directly on the skin of the affected joints
- B. Administer biological response modifiers to prevent infection
- C. Take a hot shower in the morning to decrease stiffness
- D. Cluster physical activities during the day
Correct Answer: C
Rationale: The correct answer is C: Take a hot shower in the morning to decrease stiffness. This instruction is appropriate for managing symptoms of arthritis by helping to reduce stiffness in the joints. Cold packs directly on the skin (choice A) can worsen symptoms. Administering biological response modifiers (choice B) is not a nursing role. Clustering physical activities during the day (choice D) can help manage symptoms but is not as specific or targeted as a hot shower for reducing stiffness.
Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Frequent nosebleeds
- C. Upper extremity hypotension
- D. Increased intracranial pressure
Correct Answer: A
Rationale: Coarctation causes weak or absent femoral pulses.