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A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the client in a semi-lying position.
- B. Instill 15 mL of irrigation fluid into the catheter with each flush.
- C. Subtract the amount of irrigant used from the client's urine output.
- D. Perform the irrigation using a 20-mL syringe.
Correct Answer: C
Rationale: The correct answer is C: Subtract the amount of irrigant used from the client's urine output. This is the correct action because when using open irrigation technique, the nurse needs to account for the amount of irrigant introduced into the catheter to accurately assess the client's urine output. By subtracting the amount of irrigant used from the total output, the nurse ensures an accurate measurement of the client's urine output. This is crucial for monitoring the client's renal function and fluid balance.
Choice A is incorrect as the client should ideally be in a supine position during catheter irrigation to prevent spillage. Choice B is incorrect as the amount of irrigation fluid instilled should typically be equal to the amount of urine output, not a fixed amount. Choice D is incorrect as a 60-mL syringe is usually recommended for catheter irrigation to avoid excessive force and pressure on the catheter.
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A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?
- A. Role ambiguity
- B. Sick role
- C. Role overload
- D. Role conflict
Correct Answer: C
Rationale: The correct answer is C: Role overload. Role overload occurs when an individual feels overwhelmed by the demands of multiple roles, leading to stress and difficulty in managing responsibilities. In this scenario, the partner is struggling to balance caring for their partner with dementia and managing household responsibilities, indicating an excessive workload.
A: Role ambiguity refers to uncertainty about expectations and responsibilities in a role, which is not evident in the scenario.
B: Sick role pertains to the behavior and expectations of individuals who are ill, which is not the focus of the partner's stress.
D: Role conflict involves conflicting demands from different roles, which is not the primary issue in this situation.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrist before applying the restraints.
- B. Evaluate the client's circulation every 8 hr after application.
- C. Remove the restraints every 4 hr to evaluate the client's status.
- D. Secure the restraint ties to the bed's side rails.
Correct Answer: A
Rationale: The correct answer is A: Pad the client's wrist before applying the restraints. This is important to prevent pressure injuries and ensure the client's comfort and safety. Padding helps distribute pressure and reduces the risk of skin breakdown. Choices B, C, and D are incorrect. B is not recommended as it is essential to monitor circulation frequently, not just every 8 hours. C is incorrect because restraints should not be removed without a valid reason due to the risk of injury or harm to the client. D is also wrong as restraints should be secured to parts of the bed frame, not side rails, to prevent the client from using them to injure themselves or others.
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
- A. I will return shortly after I document this in your record.
- B. Most men live a long time with prostate cancer.
- C. I am available to talk if you should change your mind.
- D. I will make a referral to a cancer support group for you.
Correct Answer: C
Rationale: The correct answer is C: "I am available to talk if you should change your mind." This response shows the nurse's willingness to provide support and maintain an open line of communication without being intrusive. It respects the client's current decision while also conveying availability for future discussions, promoting trust and rapport.
A: Incorrect. This response prioritizes documentation over the client's emotional needs.
B: Incorrect. While well-intentioned, this statement may offer false reassurance and overlooks individual variability in prognosis.
D: Incorrect. Referring to a support group without the client's consent may not align with their current preferences.
E: Incorrect. Incomplete choice.
F: Incorrect. Incomplete choice.
G: Incorrect. Incomplete choice.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
- A. Position the client at the head of the bed elevated to 30° prior to insertion of the NG tube.
- B. Remove the NG tube if the client begins to gag or choke.
- C. Apply suction to the NG tube prior to insertion.
- D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Having the client take sips of water serves to promote the insertion of the NG tube into the esophagus by facilitating swallowing and opening the esophageal sphincter, making it easier to pass the tube through. This action helps ensure proper placement of the tube in the stomach without risking insertion into the trachea or lungs.
Summary of other choices:
A: Positioning the client at the head of the bed elevated to 30° is important but is not directly related to the insertion of the NG tube.
B: Removing the NG tube if the client gags or chokes is incorrect as these are common responses during insertion, and removing the tube may lead to premature discontinuation.
C: Applying suction to the NG tube prior to insertion is unnecessary and may cause discomfort or damage to the mucosa.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
- A. I think I should take my pain medication more often
- B. since it is not controlling my pain.
- C. Breathing faster will help me keep my mind off of the pain.
- D. It might help me to listen to music while I'm lying in bed.
- E. I don't want to walk today because I have some pain.
Correct Answer: C
Rationale: The correct answer is C. The client's statement about breathing faster to keep their mind off the pain indicates understanding of distraction techniques taught preoperatively. This method helps manage pain perception. Choices A and B suggest incorrect self-medication adjustments. Choices D and E do not demonstrate understanding of pain management strategies.