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. Inflate the catheter's balloon.
- B. Lower the penis to a 45° angle.
- C. Apply lidocaine gel to the urethra.
- D. Twist the catheter gently.
Correct Answer: D
Rationale: Gentle twisting can navigate urethral obstructions safely without causing trauma.
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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 rubella
- B. A client who has tuberculosis
- C. A client who is HIV-positive
- D. A client who has had varicella
Correct Answer: D
Rationale: Prior varicella exposure prevents shingles transmission, making this roommate safe.
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma bleeds lightly when touched.
- B. The stoma is draining a small amount of liquid stool.
- C. The stoma appears dark in color.
- D. The stoma protrudes slightly from the abdomen.
Correct Answer: C
Rationale: A dark stoma may indicate ischemia, necessitating immediate provider attention.
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. Increase your intake of protein.
- B. Use your incentive spirometer.
- C. Perform regular isometric exercises.
- D. Dangle your legs over the side of the bed.
Correct Answer: D
Rationale: Dangling legs before standing allows gradual adjustment to upright posture, minimizing orthostatic hypotension risk.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Removing the client's dentures from their mouth
- B. Washing the client's face
- C. Closing the client's eyes
- D. Gathering the client's personal belongings
Correct Answer: A
Rationale: Removing dentures is a nursing task to ensure proper handling, requiring intervention.
A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
- A. Respiratory therapist
- B. Speech-language pathologist
- C. Registered dietitian
- D. Occupational therapist
Correct Answer: B
Rationale: Speech-language pathologists specialize in dysphagia, assessing and treating swallowing issues post-stroke.