Nokea
A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?
- A. Collect urine from the catheter's port.
- B. Use a sterile specimen container.
- C. Use sterile water to inflate the balloon.
- D. Instruct the client to clean from front to back with an antiseptic solution.
Correct Answer: B
Rationale: The correct answer is B: Use a sterile specimen container. This is crucial to prevent contamination of the urine sample, ensuring accurate culture and sensitivity results. Sterile container minimizes the risk of introducing bacteria from the environment. Option A is incorrect because collecting urine from the catheter's port may introduce contaminants. Option C is incorrect as sterile water is not used to inflate the balloon but rather sterile saline. Option D is incorrect because cleaning from front to back is not relevant to obtaining a urine specimen via catheterization.
You may also like to solve these questions
A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?
- A. Autonomy vs. shame and doubt
- B. Initiative vs. guilt
- C. Industry vs. inferiority
- D. Identity vs. role confusion
Correct Answer: C
Rationale: The correct answer is C: Industry vs. inferiority. In Erikson's psychosocial development theory, school-age children (around 6-12 years old) are in the stage of industry vs. inferiority. During this stage, children seek to develop a sense of competence and accomplishment by mastering new skills and tasks. This is crucial to consider in planning home care for a child recovering from an acute asthma attack as fostering a sense of industry can positively impact their self-esteem and motivation to manage their health.
Choice A: Autonomy vs. shame and doubt is more relevant to toddlers, not school-age children. Choice B: Initiative vs. guilt is about preschoolers. Choice D: Identity vs. role confusion is for adolescents. Choices E, F, G are not provided, but they would not be relevant to the developmental stage of school-age children.
A nurse is planning to reinforce teaching with a client who has a low health literacy level. Which of the following methods should the nurse use?
- A. Provide four important points.
- B. Explain information using passive voice.
- C. Use third person.
- D. Have two information sessions.
Correct Answer: A
Rationale: The correct answer is A because providing four important points can help simplify and organize information for a client with low health literacy. Breaking down information into key points can enhance understanding and retention. Choice B using passive voice may confuse the client. Choice C using third person may create distance and hinder engagement. Choice D having two information sessions could overwhelm the client. In summary, choice A is the most effective method for reinforcing teaching with a client with low health literacy.
A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions should the nurse take to help the client cope with his feelings of loss?
- A. Let the client know that this is a common problem of the aging population.
- B. Provide the client with activities to perform so he won't have time to dwell on the past.
- C. Listen attentively when the client talks about the past.
- D. Tell the client about some of the younger clients in the hospital who have experienced loss.
Correct Answer: C
Rationale: The correct answer is C. Listening attentively when the client talks about the past is essential in helping the older adult cope with feelings of grief. By actively listening, the nurse validates the client's feelings and provides a supportive environment for the client to express and process their emotions. This approach shows empathy and understanding, which can help the client feel heard and respected.
Choice A is incorrect because simply stating that it is a common problem does not address the client's individual feelings and may diminish the significance of their grief. Choice B is incorrect as it suggests avoidance rather than addressing the client's emotions directly. Choice D is incorrect as comparing the client's experience to that of younger clients may not be relevant or helpful.
A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?
- A. Measure from the client's heel to the gluteal fold.
- B. Measure the length of the client's feet.
- C. Measure from the client's heel to the popliteal space.
- D. Measure the client's ankle circumference.
Correct Answer: C
Rationale: The correct answer is C: Measure from the client's heel to the popliteal space. This is the correct action because knee-high antiembolic stockings should cover the area from the heel to just below the knee at the popliteal space. This measurement ensures proper sizing and compression effectiveness.
A: Measuring from the heel to the gluteal fold is incorrect as it would result in stockings that are too long and may impede circulation.
B: Measuring the length of the client's feet is irrelevant for determining the correct size of knee-high stockings.
D: Measuring the client's ankle circumference alone is insufficient for determining the appropriate length of knee-high stockings.
In summary, choice C is correct as it ensures the stockings fit properly, while the other choices are incorrect due to inaccuracies or irrelevance in determining the appropriate size for knee-high antiembolic stockings.
A nurse is preparing to measure a client's oral temperature. The client states that he has just had some ice chips in his mouth. Which of the following actions should the nurse take?
- A. Wait 30 min and return to measure the client's oral temperature.
- B. Provide the client a sip of warm water and wait 5 min before measuring his oral temperature.
- C. Document the inability to obtain an accurate reading of the client's oral temperature.
- D. Proceed to measure the client's oral temperature.
Correct Answer: A
Rationale: The correct answer is A: Wait 30 min and return to measure the client's oral temperature. When a client consumes ice chips, it can significantly lower their oral temperature, leading to an inaccurate reading. Waiting for 30 minutes allows the ice chips to melt and the oral temperature to stabilize. Providing warm water (choice B) may not be effective in raising the oral temperature quickly enough for an accurate reading. Documenting the inability to obtain an accurate reading (choice C) is not proactive in ensuring accurate assessment. Proceeding to measure the client's oral temperature (choice D) without allowing time for the ice chips to melt will likely result in an inaccurate reading.