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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. Inflate the catheter's balloon.
- C. Twist the catheter gently.
- D. Lower the penis to a 45° angle.
Correct Answer: C
Rationale: Twisting gently can navigate resistance (e.g., prostate) without forcing or inflating prematurely.
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A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has tuberculosis
- B. A client who has rubella
- C. A client who has had varicella
- D. A client who is HIV-positive
Correct Answer: C
Rationale: A client with prior varicella is immune to herpes zoster (same virus), minimizing transmission risk.
A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Dangle your legs over the side of the bed.
- B. Use your incentive spirometer.
- C. Increase your intake of protein.
- D. Perform regular isometric exercises.
Correct Answer: A
Rationale: Dangling legs before standing allows gradual adjustment to upright posture, reducing orthostatic hypotension risk.
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Reposition the client once every 4 hr.
- B. Provide oral care to the client once every 8 hr.
- C. Place the head of the client's bed flat.
- D. Use a fan to circulate air in the client's room.
Correct Answer: D
Rationale: A fan improves air movement, easing dyspnea in end-of-life care.
A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?
- A. Wear sterile gloves when handling the stool specimen.
- B. Have the client defecate into a bedpan that contains a small amount of water.
- C. Repeat the test three times using the same stool specimen.
- D. Ensure that the stool specimen does not contain urine.
Correct Answer: D
Rationale: Urine can contaminate the specimen, affecting the accuracy of the fecal occult blood test.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. Family history of osteoporosis
- B. Type 1 diabetes mellitus
- C. Orthostatic hypotension
- D. BMI of 24
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to chronic hyperglycemia affecting blood vessels.