Nokea
A nurse is Inserting an indwelling urinary catheter to a male client. Which of the following actions should the nurse take?
- A. Cleanse the tip of the penis in a side to side motion
- B. Pick up the catheter 13 cm (5 in) from its tip
- C. Perform the cleansing procedure with a fresh swab two times
- D. Lift the penis so that it is perpendicular to the client's body
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps straighten the urethra, allowing for easier insertion of the catheter. Lifting the penis also reduces the risk of trauma or injury during the procedure. Cleaning the tip of the penis in a side-to-side motion (choice A) can introduce bacteria into the urethra. Picking up the catheter 13 cm (5 in) from its tip (choice B) may contaminate the sterile end. Performing the cleansing procedure with a fresh swab two times (choice C) is not necessary and may increase the risk of irritation to the client's skin.
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A nurse in an antepartum unit is caring for a client.
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and
spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours
ago and is a greenish color," Client also reports contractions began about 4 hr. ago and have
become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad.
Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min.
Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this
pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
2020:
Contractions occurring every 4 to 5 min, lasting 40 to 60 seconds. Small amount of bloody show
noted when changing disposable pad on bed. Client rates contraction pain as a 5 on a scale of 0
to 10, breathing well through contractions., FHR 168/min, minimal variability. Client denies
epigastric pain or visual disturbances. Trace of edema noted to bilateral lower extremities.
2230:
Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by
anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min
with moderate variability. Accelerations present, no decelerations noted.
Vital Signs
2230:
Temperature 38° C (100.4° F)
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
Select the findings that indicate the interventions have been effective.
- A. Client rates pain with contractions as a 3 on a scale of 0 to 10
- B. Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds
- C. Accelerations present, no decelerations noted
- D. Heart rate 88/min
- E. Blood pressure 122/80 mm Hg
- F. Temperature 38° C(100.4° F)
Correct Answer: A,C
Rationale: Effective pain relief (client rates pain as 3) and normal FHR patterns indicate successful interventions.
A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus.
Which of the following action should the nurse take?
- A. Determine if the AP has the skills to perform the test.
- B. Help the AP performed the blood glucose test
- C. Assign the AP to ask the client is taking his diabetic medication today
- D. Have AP check the medical record for prior blood glucose test results
Correct Answer: A
Rationale: The correct answer is A because the nurse should first assess if the AP has the necessary skills to perform the blood glucose test. This step is crucial to ensure patient safety and accurate test results. Helping the AP perform the test (B) without assessing their skills can lead to errors. Assigning the AP to ask about medication (C) is not directly related to the task at hand. Having the AP check records (D) is important but should come after confirming their skills. The other choices are not relevant to the immediate situation.
A nurse is assessing a client following an esophagogastroduodenoscopy.
Which of the following findings should the nurse report to the provider?
- A. Abdominal pain
- B. Belching
- C. Fatulence
- D. Sore throat
Correct Answer: A
Rationale: The correct answer is A: Abdominal pain. Abdominal pain is a significant finding that could indicate underlying health issues and requires immediate attention from the provider for further assessment and intervention. Belching and flatulence are common gastrointestinal symptoms that may not necessarily warrant immediate reporting. Sore throat, unless severe or persistent, can often be managed with over-the-counter remedies. It is important to prioritize reporting symptoms that could be indicative of serious conditions to ensure timely and appropriate care.
A nurse is caring for a client whose child died from cancer. The client states 'it's hard to go on without him'. which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?
- B. Has anyone in your family committed suicide?
- C. Is there anyone you would like involved in your care?
- D. Are you thinking about ending your life?
Correct Answer: D
Rationale: The correct answer is D: Are you thinking about ending your life? This question is crucial as it directly addresses the client's statement about finding it hard to go on. It assesses the client's suicidal ideation and determines the level of risk for self-harm or suicide. It prioritizes the client's safety and well-being.
Choice A is incorrect because it does not directly address the immediate concern of potential suicide risk. Choice B is irrelevant and may lead to unnecessary distress for the client. Choice C is important but not as urgent as assessing for suicidal ideation.
The nurse is continuing to care for the client.
History and Physical
Day 1, 0900:
A 52-year-old client brought to emergency department by adult child. Client is alert and oriented
to person and time but does not know where they are. No history of substance use according to
client's adult child. Client exhibits constant movements and poor concentration. Hair and
clothing are unclean. Appears to be listening to unseen others. Skin turgor poor.
The nurse is providing teaching about lithium to the client and client's adult child. Select the 3 statements the nurse should include.
- A. Blurred vision is an expected adverse effect pf this medication
- B. It will take at least a week before this medication reaches a therapeutic level.
- C. This medication can cause nausea and drowsiness.
- D. You will be placed on a low sodium diet while taking this medication.
- E. This medication can cause weight gain.
Correct Answer: B,C,E
Rationale: Blurred vision is not typical; lithium takes time to reach therapeutic levels, causes nausea/drowsiness, and often leads to weight gain. A low-sodium diet is contraindicated due to risk of toxicity.