Nokea
A client who has been complaining of dysuria, urinary frequency, and discomfort in the suprapubic area.
After evaluating the results, the nurse should order a repeat urinalysis based on which of the following findings?
- A. Negative glucose.
- B. RBCs present.
- C. No WBCs or RBCs reported.
- D. Specific gravity 1.018.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates a bladder infection. (1) glucose increases during the inflammation process; it is not a primary component in determining urinary tract infections (2) not as complete a response as answer choice #3 (3) correct-with the client's complaints, WBCs and RBCs should be present; WBCs are a response to the inflammation process and irritation of the urethra; RBCs are increased when bladder mucosa is irritated and bleeding (4) indicates the concentration of the urine
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A patient has a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the woman in respiratory distress.
It is MOST important for the nurse to
- A. notify the physician immediately to remove the tube.
- B. elevate the head of the bed and administer oxygen.
- C. cut the balloon ports and remove the tube.
- D. call a code and begin rescue breathing.
Correct Answer: C
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) need to remove tube immediately to provide for airway (2) does not provide a patent airway (3) correct-scissors always secured at the bedside, remove tube if observe signs of respiratory distress or airway obstruction caused by upward displacement of esophageal balloon (4) unnecessary to call code until respiratory arrest occurs, then establish a patent airway first
The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client?
- A. Protection for the granulation tissue
- B. Heal infection
- C. Debride eschar
- D. Keep the tissue intact
Correct Answer: D
Rationale: Keep the tissue intact. Dry, intact eschar requires no intervention unless signs of infection appear.
The nurse is teaching a client about the toxicity of digoxin. Which one of the following statements made by the client to the nurse indicates more teaching is needed?
- A. I may experience a loss of appetite.'
- B. I can expect occasional double vision.'
- C. Nausea and vomiting may last a few days.'
- D. I must report a bounding pulse of 62 immediately.'
Correct Answer: D
Rationale: Slow heart rate is related to increased cardiac output and an intended effect of digoxin. The ideal heart rate is above 60 BPM with digoxin. The client needs further teaching.
Which action is most likely to ensure the safety of the nurse while making a home visit?
- A. Observe no evidence of weapons in the home during the visit
- B. Prior to the visit, review the client's record for any previous entries about violence
- C. Remain alert at all times and leave if cues suggest the home is not safe
- D. Carry a cell phone, pager and/or hand held alarm for emergencies
Correct Answer: C
Rationale: Remain alert at all times and leave if cues suggest the home is not safe. No person or equipment can guarantee nurses' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards. Observe surroundings when parking, walking to the client's door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.
The nurse is inserting an indwelling urinary catheter in an adult woman. The nurse locates landmarks before inserting the catheter. The urethral opening is located:
- A. above the clitoris.
- B. behind the vagina.
- C. between the clitoris and the vagina.
- D. between the vagina and the rectum.
Correct Answer: C
Rationale: The female urethral opening is located between the clitoris and vagina, a key landmark for catheter insertion to avoid incorrect placement.