Nokea
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A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Clamp the catheter tubing distal to the sampling port for 15 min.
- B. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen.
- D. Empty the urine into a sterile container labeled with the client identifiers.
- E. Document in the client's electronic medical record that the specimen was sent to the laboratory
- F. Wash hands before starting.
- G. Check the client's ID band.
Correct Answer:
Rationale: Clamping allows urine to collect, wiping ensures sterility, aspirating collects the sample, transferring maintains sterility, and documenting completes the process.
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A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hr of using nitroglycerin?
- A. Atorvastatin
- B. Sildenafil
- C. Omeprazole
- D. Metformin
- E. Aspirin
- F. Ibuprofen
- G. Warfarin
Correct Answer: B
Rationale: Sildenafil (Viagra) with nitroglycerin can cause severe hypotension; other meds don't interact significantly.
A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will use a skin sealant before I apply the bag.
- B. I will use moisturizing soap to clean around the stoma before applying the bag.
- C. I will cut the wafer opening one-fourth of an inch larger than the stoma
- D. I will need to empty the bag every 4 to 6 hours.
Correct Answer: A
Rationale: Using a skin sealant protects the peristomal skin, showing understanding of ileostomy care. Moisturizers can interfere, the wafer should be 1/8 inch larger, and emptying frequency varies but isn't the best indicator here.
A nurse in a provider's office is assisting in the care of a client. For each potential provider's prescription, which is anticipated for the client?
- A. Administer an iron supplement.
- B. Collaborate with a nutritional consultant.
- C. Place the client on a low sodium diet.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Given the client's vegan diet, fatigue, weakness, pale mucous membranes, and rapid pulse (Exhibit 1), iron deficiency anemia is likely. Administering an iron supplement is anticipated it corrects low hemoglobin, a common vegan shortfall without meat or fortified sources, directly addressing the suspected etiology. Nutritional consultation helps long-term, but immediate supplementation is urgent for symptom relief and oxygen delivery. A low-sodium diet suits heart failure or hypertension, not anemia blood pressure (132/60 to 102/50 mm Hg) reflects orthostasis, not sodium issues. Fluid restriction applies to fluid overload, not here, where hydration supports circulation. Iron supplementation aligns with anemia management guidelines (e.g., ferrous sulfate), offering rapid hematologic improvement, making it the expected prescription for this presentation.
A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr. to an older adult client who has rhinitis. The amount available is diphenhydramine syrup 12.5 mg/5 mL How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 10
Rationale: Calculation: (25 mg / 12.5 mg) × 5 mL = 10 mL. This delivers the prescribed dose accurately.
A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?
- A. Administer a prescribed oral dose of trazodone to the client.
- B. Encourage the client to ambulate with a staff member.
- C. Isolate the client in their room.
- D. Apply bilateral wrist restraints to the client.
Correct Answer: A
Rationale: Trazodone, if prescribed, can calm agitation in Alzheimer's safely. Ambulation may help but isn't immediate, isolation can worsen agitation, and restraints are a last resort.