Nokea
A nurse is preparing to irrigate a client's indwelling catheter through a closed, intermittent system. Which of the following steps must the nurse take as part of this process?
- A. Use sterile solution at room temperature
- B. Position the client in a comfortable position
- C. Clamp the catheter at the level above the injection port
- D. Inject sterile solution through the injection port into the catheter
Correct Answer: D
Rationale: When performing closed intermittent system catheter irrigation, the nurse should use sterile solution at room temperature with sterile technique. It is important to position the client comfortably for easy access to the catheter site and to assess the abdomen during the procedure. Clamping the catheter should be done below the level of the injection port, not above. The correct step is to inject sterile solution through the injection port into the catheter, allowing the fluid to travel up the catheter to irrigate the tubing and the bladder.
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A client's intake and output are being calculated by a nurse. During the last shift, the client consumed ½ cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client also urinated 250 cc and had 2 bowel movements. What is this client's intake and output for this shift?
- A. 420 cc intake, 250 cc output
- B. 300 cc intake, 250 cc output
- C. 550 cc intake, 550 cc output
- D. 300 cc intake, 550 cc output
Correct Answer: A
Rationale: The correct answer is 420 cc intake and 250 cc output for this shift. To calculate the intake, ½ cup of gelatin (approximately 120 cc) and 300 cc of water should be added together, resulting in 420 cc. Food intake like the chicken breast and green beans is not converted to cc's but may be documented for hospital protocol. Output includes urine (250 cc in this case) and other forms like vomit, diarrhea, or gastric suction. Bowel movements are not converted to cc's, but the nurse may need to document the number of stools passed. Choices B, C, and D are incorrect because they do not accurately reflect the intake and output calculations based on the information provided.
Which of the following statements best describes substance P?
- A. Substance P decreases a client's sensitivity to pain
- B. Substance P levels are drawn before administration of narcotic analgesics
- C. Substance P is found in the brain and is responsible for pain control and management of depression
- D. Substance P is found in the dorsal horn of the spinal column
Correct Answer: D
Rationale: Substance P is a neurotransmitter found in the brain and the dorsal horn of the spinal column, not just in the brain. It is associated with pain transmission and modulation. Substance P is known to cause inflammation, edema, and pain. While it plays a role in pain perception, it does not decrease a client's sensitivity to pain (Choice A), nor are its levels typically drawn before administering narcotic analgesics (Choice B). Although substance P is involved in pain control, it is not responsible for managing depression (Choice C). Therefore, the correct statement is that substance P is found in the dorsal horn of the spinal column.
A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?
- A. Administer the feeding as ordered
- B. Pull the feeding tube out approximately 3 cm
- C. Flush the feeding tube with 60 cc of water
- D. Contact the physician
Correct Answer: A
Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.
A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?
- A. Assist the client to lie in the semi-Fowler position
- B. Apply lubricating jelly to the tip of the catheter before insertion
- C. Instill a total of 30cc of fluid into the client's rectum
- D. Ask the client to hold the solution in for 30 seconds
Correct Answer: B
Rationale: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema. Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.
Match the abbreviation with the correct definition:
- A. bid: twice a day
- B. tid: three times a day
- C. ac: before meals
- D. pc: after meals
Correct Answer: C
Rationale: The abbreviation 'ac' stands for 'ante cibum,' which means 'before meals.' 'Bid' means twice a day. 'Tid' means three times a day, and 'pc' means after meals. When interpreting medical abbreviations, it is crucial to understand their precise meanings to ensure accurate communication and patient care.