Nokea
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?
- A. Insert the catheter 7.5 cm (3 in) into the urethra.
- B. Insert the catheter until urine flow is established.
- C. Cleanse the catheter with sterile water before insertion.
- D. Insert the catheter 5 cm (2 in) into the urethra.
Correct Answer: B
Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.
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A nurse is caring for a client who has chronic kidney disease and reports nausea. The nurse should identify that this client is at risk for which of the following imbalances?
- A. Metabolic alkalosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: The correct answer is B: Metabolic acidosis. Clients with chronic kidney disease are at risk for metabolic acidosis because the kidneys are unable to effectively excrete acids, leading to an accumulation of acid in the body. This metabolic imbalance can result in symptoms like nausea. Choices A, C, and D are incorrect. Metabolic alkalosis is not typically associated with chronic kidney disease. Respiratory alkalosis is more commonly seen in conditions such as hyperventilation. Respiratory acidosis, on the other hand, is often linked to conditions affecting the lungs or respiratory system, not primarily kidney disease.
A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia. Which of the following actions is the nurse's priority?
- A. Consult with a case manager regarding insurance coverage.
- B. Counsel caregivers on respite care options.
- C. Ensure that the client has a referral for physical therapy.
- D. Refer the client to a local stroke support group.
Correct Answer: C
Rationale: The correct answer is C: 'Ensure that the client has a referral for physical therapy.' For a client with left-sided hemiplegia, physical therapy is crucial in restoring function and mobility. It is the nurse's priority to ensure the client receives the necessary rehabilitation services. Consulting with a case manager about insurance coverage (Choice A) is important but not the priority at this stage. Counseling caregivers on respite care options (Choice B) and referring the client to a local stroke support group (Choice D) are also valuable but not as essential as ensuring the client has access to physical therapy for rehabilitation.
A nurse is caring for a client who is 1 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take?
- A. Irrigate the catheter with 0.9% sodium chloride.
- B. Reposition the catheter.
- C. Notify the provider.
- D. Increase the rate of the continuous bladder irrigation.
Correct Answer: A
Rationale: In this situation, the nurse should irrigate the catheter with 0.9% sodium chloride to help relieve any obstruction and ensure proper urinary drainage following a TURP. Repositioning the catheter may not address the underlying issue of obstruction. Notifying the provider should be done after attempting to resolve the drainage issue. Increasing the rate of continuous bladder irrigation is not the initial intervention for a catheter that is not draining.
A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse expect?
- A. Clay-colored stools.
- B. Hypertension.
- C. Stridor.
- D. Elevated temperature.
Correct Answer: A
Rationale: Clay-colored stools are a classic finding in a client with cirrhosis. Cirrhosis can lead to impaired bile flow, resulting in pale or clay-colored stools due to a lack of bilirubin in the stool. Hypertension, stridor, and elevated temperature are not typically associated with cirrhosis. Hypertension may occur in cirrhosis but is not a consistent finding, stridor is more commonly associated with upper airway obstruction, and elevated temperature may indicate an infection rather than a direct result of cirrhosis.
A nurse is reviewing the laboratory values of a client who is receiving heparin therapy for deep-vein thrombosis. Which of the following values should the nurse report to the provider?
- A. INR 2.0
- B. Platelet count 150,000/mm3
- C. aPTT 60 seconds
- D. WBC count 8,000/mm3
Correct Answer: C
Rationale: The correct answer is C: aPTT 60 seconds. An aPTT of 60 seconds is above the therapeutic range for clients on heparin therapy and indicates a risk of bleeding, so it should be reported to the provider. INR of 2.0 is within the therapeutic range for clients on heparin therapy, so it does not require immediate reporting. Platelet count of 150,000/mm3 and WBC count of 8,000/mm3 are within normal ranges and not directly related to heparin therapy, so they do not need to be reported in this context.