Nokea
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.
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A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse use?
- A. Femoral
- B. Carotid
- C. Popliteal
- D. Radial
Correct Answer: B
Rationale: The correct answer is B: Carotid. The carotid pulse site should be used when assessing circulation to the brain in a client with cardiogenic shock because it is the closest pulse site to the brain. The carotid artery supplies blood directly to the brain, making it the most accurate site to assess perfusion to this vital organ.
A: Femoral, C: Popliteal, and D: Radial are not ideal pulse sites for assessing circulation to the brain in a client with cardiogenic shock because they are further away from the brain compared to the carotid artery. Using these sites may not provide an accurate representation of cerebral perfusion in this critical situation.
A nurse is reinforcing dietary teaching with a client who wants to reduce solid fat intake. Which of the following instructions should the nurse include?
- A. Replace tub margarine with stick margarine.
- B. Use safflower oil instead of butter when baking.
- C. Consume 2% or whole milk.
- D. Choose ground beef that is at least 80% lean meat.
Correct Answer: B
Rationale: The correct answer is B: Use safflower oil instead of butter when baking. Safflower oil is a healthier alternative to butter as it is a liquid fat and contains unsaturated fats, which are better for heart health and reducing solid fat intake. Butter, on the other hand, is a solid fat high in saturated fats, which can increase cholesterol levels. This substitution promotes a lower intake of solid fats while still allowing for baking needs. The other choices are incorrect because: A) Stick margarine is also a solid fat high in trans fats, not suitable for reducing solid fat intake. C) Whole milk contains solid fats, so opting for low-fat or skim milk would be better. D) Ground beef with at least 80% lean meat still contains solid fats, so choosing leaner options like 90% lean or ground turkey would be more beneficial.
A nurse is reinforcing teaching with a client about crutch walking using the swing-through gait. Which of the following statements should the nurse include?
- A. Look down at your feet before moving the crutches.
- B. Place one crutch forward with the opposite foot and then place the second crutch forward with the other foot.
- C. Move both crutches forward, then lift and move your body past the crutches.
- D. Bear your weight against the underarm crutch pads.
Correct Answer: C
Rationale: The correct answer is C: Move both crutches forward, then lift and move your body past the crutches. This statement correctly describes the swing-through gait technique where both crutches are moved forward simultaneously followed by the client lifting and moving their body past the crutches. This technique helps maintain balance and stability during crutch walking. Looking down at your feet before moving the crutches (Choice A) is incorrect as it can cause the client to lose their balance. Placing one crutch forward with the opposite foot and then the second crutch forward with the other foot (Choice B) is the incorrect description of the swing-to gait technique. Bearing weight against the underarm crutch pads (Choice D) is incorrect as it can cause discomfort and potential nerve damage.
A nurse is reinforcing teaching with a 40-year-old female client about preventive health screenings. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should have my skin checked every 5 years for cancer.
- B. I will need to have a mammogram every year now.
- C. I should have my first colonoscopy when I turn 65.
- D. I will be checked for uterine cancer every 2 years.
Correct Answer: B
Rationale: The correct answer is B: "I will need to have a mammogram every year now." This statement indicates an understanding of preventive health screenings for a 40-year-old female. Mammograms are recommended annually starting at age 40 to screen for breast cancer. Choice A is incorrect as skin checks for cancer should be more frequent than every 5 years. Choice C is incorrect as the first colonoscopy is recommended at age 50, not 65. Choice D is incorrect as uterine cancer screening is typically not done every 2 years.
A nurse is reinforcing teaching with a 40-year-old female client about preventive health screenings. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should have my skin checked every 5 years for cancer.
- B. I will need to have a mammogram every year now.
- C. I should have my first colonoscopy when I turn 65.
- D. I will be checked for uterine cancer every 2 years.
Correct Answer: B
Rationale: The correct answer is B: "I will need to have a mammogram every year now." Mammograms are recommended for women starting at age 40 to screen for breast cancer. Annual mammograms help detect any abnormalities early, improving the chances of successful treatment. Choice A is incorrect as skin checks should be done annually. Choice C is incorrect as the first colonoscopy is usually recommended at age 50. Choice D is incorrect as there is no standard screening for uterine cancer every 2 years.