Nokea
A nurse is inserting an indwelling urinary catheterfor a male patient. Which action will the nurse take?
- A. Hold the shaft of the penis at a 60-degree angle.
- B. Hold the shaft of the penis with the dominant hand.
- C. Cleanse the meatus 3 times with the same cotton ball from clean to dirty.
- D. Cleanse the meatus with circular strokes beginning at the meatus and working outward.
Correct Answer: D
Rationale: The correct answer is D because cleansing the meatus with circular strokes starting at the meatus and moving outward helps prevent the introduction of bacteria into the urethra. This technique minimizes the risk of urinary tract infections. Holding the shaft at a 60-degree angle (A) or with the dominant hand (B) is not necessary for catheter insertion. Cleansing the meatus 3 times with the same cotton ball (C) can introduce more bacteria and is not recommended.
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A nurse has made a referral to a grief support group, knowing that many individuals find these both comforting and beneficial after the death of a loved one. What is the most important accomplishment available by attending a grief support group?
- A. Providing a framework for incorporating the old life into the new life
- B. Normalizing adaptation to a continuation of the old life
- C. Aiding in adjusting to using old, familiar social skills
- D. Normalization of feelings and experiences
Correct Answer: D
Rationale: The correct answer is D: Normalization of feelings and experiences. Attending a grief support group helps individuals feel validated and understood by others who are going through similar emotions. This normalization can reduce feelings of isolation and provide a sense of belonging, which is crucial in the grieving process. It also allows individuals to recognize that their feelings and experiences are common reactions to loss.
Choice A is incorrect because a grief support group focuses more on accepting and processing the new reality rather than incorporating the old life into it. Choice B is incorrect as it suggests maintaining the old life rather than adjusting to a new normal. Choice C is incorrect because the focus of a grief support group is not solely on social skills but on emotional support and coping mechanisms.
A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do?
- A. Call the physician and ask for the order to be confirmed.
- B. Follow the order because this position will help keep the retinal repair intact.
- C. Instruct the patient to maintain this position to prevent bleeding.
- D. Reposition the patient after the first dressing change.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Prone position post retinal detachment repair helps the gas bubble or silicone oil stay against the retina to support healing.
2. This position prevents the bubble/oil from moving and causing further detachment.
3. Repositioning can jeopardize the surgical repair and lead to complications.
4. Calling the physician (A) is unnecessary as the order is clear.
5. Instructing the patient to prevent bleeding (C) is not related to the positioning after retinal detachment repair.
6. Repositioning after the first dressing change (D) contradicts the initial order and risks complications.
Following a recent history of dyspareunia and lower abdominal pain, a patient has received a diagnosis of pelvic inflammatory disease (PID). When providing health education related to self-care, the nurse should address which of the following topics? Select all that apply.
- A. Use of condoms to prevent infecting others
- B. Appropriate use of antibiotics
- C. Taking measures to prevent pregnancy
- D. The need for a Pap smear every 3 months E) The importance of weight loss in preventing symptoms
Correct Answer: A
Rationale: The correct answer is A: Use of condoms to prevent infecting others. This is important because PID is a sexually transmitted infection and using condoms can help prevent transmission to sexual partners. It is crucial to address this topic to ensure the patient understands the importance of safe sex practices.
The other choices are incorrect:
B: Appropriate use of antibiotics - While antibiotics are used to treat PID, this choice does not address self-care education for prevention.
C: Taking measures to prevent pregnancy - While important for overall health, preventing pregnancy is not directly related to self-care for PID.
D: The need for a Pap smear every 3 months - Pap smears are not directly related to PID management or prevention.
E: The importance of weight loss in preventing symptoms - Weight loss is not a direct self-care measure for managing or preventing PID.
You are caring for a patient who has been diagnosed with genital herpes. When preparing a teaching plan for this patient, what general guidelines should be taught?
- A. Thorough handwashing is essential.
- B. Sun bathing assists in eradicating the virus.
- C. Lesions should be massaged with ointment.
- D. Self-infection cannot occur from touching lesions during a breakout.
Correct Answer: A
Rationale: The correct answer is A because thorough handwashing is essential in preventing the spread of genital herpes. This helps reduce the risk of transmission to other parts of the body or to other individuals. Sunbathing (B) does not eradicate the virus and can actually worsen symptoms. Massaging lesions with ointment (C) can aggravate the sores and lead to further infection. Self-infection (D) can occur from touching lesions during a breakout due to the highly contagious nature of the virus. Therefore, teaching the patient about thorough handwashing is crucial in managing and preventing the spread of genital herpes.
A student nurse is caring for a patient who has undergone a wide excision of the vulva. The student should know that what action is contraindicated in the immediate postoperative period?
- A. Placing patient in low Fowlers position
- B. Application of compression stockings
- C. Ambulation to a chair
- D. Provision of a low-residue diet
Correct Answer: B
Rationale: The correct answer is B: Application of compression stockings. Immediately after a wide excision of the vulva, compression stockings should be avoided as they can increase the risk of blood clots. Placing the patient in a low Fowler's position helps with comfort and promotes healing. Ambulation to a chair aids in preventing complications like pneumonia and deep vein thrombosis. Providing a low-residue diet is appropriate postoperatively to prevent straining during bowel movements.