Nokea
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply antiseptic ointment to the tip of my penis.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will clamp the tube when I go for a walk.
Correct Answer: B
Rationale: Keeping the drainage bag below waist level prevents backflow and reduces infection risk.
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A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Client instructed on self-care needs.
- B. Episiotomy approximated. 3 cm (1.18 in) in length.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: B
Rationale: Documenting the status of the episiotomy provides essential information regarding healing and recovery, a priority in postpartum care.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Postpone the procedure until the staff contacts the guardian.
- B. Obtain consent from the client.
- C. Request that the provider sign the consent form.
- D. Prepare the client for surgery with implied consent.
Correct Answer: D
Rationale: In emergencies, implied consent allows life-saving procedures when delaying could harm the client.
The client is at risk for ___ as evidenced by the client's ___
- A. Aspiration
- B. Dysphagia
Correct Answer: A,B
Rationale: A: Dysphagia increases aspiration risk. B: Food stuck in mouth and hoarseness indicate swallowing difficulty.
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.
- A. Encourage the client to splint the abdomen when coughing.
- B. Administer acetaminophen.
- C. Administer ondansetron.
- D. Remind the client to use the incentive spirometer five times per hr.
- E. Encourage the client to cough and deep breathe.
- F. Plan to ambulate the client 30 min after the next analgesic is administered.
Correct Answer: A,D,E,F
Rationale: A: Splinting reduces pain during coughing. D: Incentive spirometry prevents atelectasis. E: Coughing and deep breathing clear secretions. F: Ambulation post-analgesic promotes lung expansion.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink two hot cups of coffee each morning.
- B. I take a prescribed opioid pain medication at bedtime.
- C. I love to eat apples and black-eyed peas.
- D. I drink an average of 2,000 milliliters of water daily.
Correct Answer: B
Rationale: Opioids slow bowel motility, increasing constipation risk.