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. Inflate the catheter's balloon.
- C. Lower the penis to a 45° angle.
- D. Twist the catheter gently.
Correct Answer: C
Rationale: Lowering the penis aligns the urethra, reducing resistance.
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A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Request a prescription renewal from the provider every 36 hr.
- B. Check the client's range of motion every 6 hr.
- C. Secure the restraints with a square knot.
- D. Make sure two fingers fit under the restraints.
Correct Answer: D
Rationale: Ensuring two fingers fit prevents excessive tightness and circulation issues.
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?
- A. Place a pillow between the client's legs prior to logrolling.
- B. Place the client in semi-Fowler's position prior to logrolling.
- C. Place the client's arms above her head prior to logrolling.
- D. Place the bed in the lowest position before logrolling the client.
Correct Answer: A
Rationale: A pillow between legs maintains spinal alignment during logrolling post-laminectomy.
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: D
Rationale: Sedentary lifestyle is a priority as it poses immediate health risks like thrombosis or muscle atrophy.
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. Provide oral care to the client once every 8 hr.
- B. Reposition the client once every 4 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: B
Rationale: Repositioning helps relieve dyspnea by improving lung expansion and comfort.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
- B. Unlock and remove the inner cannula.
- C. Scrub the inside and outside of the inner cannula with a small brush.
- D. Cleanse the stoma site with 0.9% sodium chloride solution.
- E. Wipe the inside of the inner cannula with a folded pipe cleaner.
Correct Answer: A,B,C,E,D
Rationale: A: Prepare solution. B: Remove cannula. C: Scrub cannula. E: Wipe cannula. D: Cleanse stoma ensures sterile technique.