Nokea
A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Contractures of extremities
- B. Hypertension
- C. Diarrhea
- D. Crackles in the lungs
- E. Pressure ulcers
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Contractures of extremities occur due to prolonged immobility. Crackles in the lungs can result from immobility-related respiratory complications. Pressure ulcers are common in immobile clients due to prolonged pressure on bony prominences. Hypertension and diarrhea are not typically associated with complications of immobility.
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A charge nurse is assisting a newly-licensed nurse to insert an indwelling urinary catheter for a male client. Which of the following actions requires the charge nurse to intervene?
- A. Lubricates the first 2.5 to 5 cm (1 to 2 in) of the catheter tubing
- B. Lubricates the first 15 to 17.5 cm (6 to 7 in) of the catheter
- C. Secures the tubing to the client's upper thigh
- D. Secures the tubing to the client's lower abdomen.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The correct action for inserting an indwelling urinary catheter in a male client is to lubricate the first 15 to 17.5 cm (6 to 7 in) of the catheter, not just the first 2.5 to 5 cm (1 to 2 in). This is crucial to ensure smooth insertion and prevent trauma to the urethra. Therefore, the charge nurse should intervene and guide the newly-licensed nurse to lubricate the appropriate length of the catheter tubing.
Summary of Incorrect Choices:
B: Lubricating the first 15 to 17.5 cm (6 to 7 in) of the catheter is the correct action, not an intervention.
C: Securing the tubing to the client's upper thigh is a proper step to prevent pulling on the catheter, not requiring intervention.
D: Securing the tubing to the client's lower abdomen is also a standard practice to prevent dislod
A nurse is supervising a newly licensed nurse who is female while she performs postmortem care on a male client who is Muslim. Which of the following actions by the newly licensed nurse should prompt the nurse to intervene?
- A. Leaves the client's dentures in his mouth
- B. Prepares to cleanse the client's body
- C. Disconnects the cardiac monitor from the client
- D. Removes soiled linens from the client
Correct Answer: B
Rationale: In Islamic practices, same-gender family members or religious personnel should perform body cleansing. A female nurse cleansing a male client would require intervention.
A nurse is collecting data from the mother of a toddler. Which of the following activities should the nurse expect the toddler to be able to perform?
- A. Jump rope
- B. Ride a tricycle
- C. Print letters and numbers
- D. Use scissors to cut out a picture
Correct Answer: B
Rationale: The correct answer is B: Ride a tricycle. Toddlers typically develop gross motor skills around 2 years old, making riding a tricycle a suitable activity. Jumping rope (choice A) requires more advanced coordination and balance. Printing letters and numbers (choice C) involves fine motor skills that develop later. Using scissors (choice D) also requires more advanced fine motor skills.
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
- A. Position the client supine.
- B. Have the client bear down during removal.
- C. Cleanse the perineal area with an antiseptic.
- D. Deflate the balloon halfway and then pull out the catheter.
Correct Answer: A
Rationale: The correct answer is A: Position the client supine. This position allows for easier access to the urinary catheter and minimizes the risk of spillage or contamination. Supine position also provides better comfort and stability for the client during the catheter removal process.
Summary of other choices:
B: Having the client bear down during removal can increase the risk of injury and discomfort.
C: Cleaning the perineal area with an antiseptic is important but should be done after removing the catheter.
D: Deflating the balloon halfway and pulling out the catheter can cause pain and discomfort for the client and may lead to trauma.
A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
- A. Increase the client's oral fluid intake.
- B. Initiate humidification therapy.
- C. Encourage the client to cough and deep breathe.
- D. Raise the head of the bed.
Correct Answer: D
Rationale: The correct action is to raise the head of the bed (Choice D) first. This helps improve ventilation and oxygenation by optimizing lung expansion and reducing the work of breathing. Elevating the head of the bed promotes better oxygen exchange in pneumonia patients. Increasing oral fluid intake (Choice A) may be beneficial but not the priority in this scenario. Humidification therapy (Choice B) may help with secretions but does not directly address the oxygenation concern. Encouraging cough and deep breathing (Choice C) is important for lung hygiene but should come after ensuring adequate oxygenation.