Nokea
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Apply lidocaine gel to the urethra.
- B. Twist the catheter gently.
- C. Inflate the catheter's balloon.
- D. Lower the penis to a 45° angle.
Correct Answer: B
Rationale: Gently twisting the catheter may navigate past resistance, often due to the prostatic urethra.
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A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. The sterile solution is poured with the bottle held over the field.
- B. Unnecessary sterile items are placed on the field.
- C. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
Correct Answer: A
Rationale: Pouring solution with the bottle over the field risks contamination from touch or splash.
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Tie the belt restraint to the side rail of the bed.
- C. Check the client's skin integrity every 4 hr.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown protects skin and ensures comfort.
A nurse is collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign?
- A. A
- B. B
- C. C
- D. D
Correct Answer: C
Rationale: A positive Chvostek's sign (twitching of facial muscles when tapping the facial nerve) is associated with hypomagnesemia; assumed as C due to incomplete options.
Findings that require immediate follow-up: deep tendon reflexes 4+, generalized weakness, mild leg cramping, heart rate irregular, bowel sounds hyperactive x 4 quadrants
- A. Deep tendon reflexes 4+
- B. Generalized weakness
- C. Mild leg cramping
- D. Heart rate irregular
- E. Bowel sounds hyperactive x 4 quadrants
Correct Answer: A,B,C,D,E
Rationale: A: Hyperreflexia suggests magnesium deficiency. B,C: Weakness and cramping indicate electrolyte issues. D: Irregular heart rate risks arrhythmia. E: Hyperactive bowels may relate to vomiting.
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 1â„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 skin barrier for 30 seconds ensures adhesion, preventing leakage.