Nokea
After inserting an indwelling catheter into an adult male, the nurse secures the catheter by:
- A. taping it lateral to the client's thigh.
- B. taping it upward to the client's abdomen.
- C. taping it downward to the client's thigh.
- D. making a loop with the tubing and taping the tubing to the client's thigh.
Correct Answer: A
Rationale: Taping the catheter laterally to the thigh prevents tension or dislodgement while allowing mobility. Upward or downward taping risks kinking, and looping increases infection risk.
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The nurse is performing tracheostomy care for a client who has a tracheostomy tube with a disposable inner cannula. Which of the following actions should the nurse take?
- A. Cleanse the stoma using an alcohol-based cleaning solution.
- B. Discontinue humidification once tracheostomy care is complete.
- C. Suction the tracheostomy tube prior to removing the inner cannula.
- D. Remove the outer cannula of the tracheostomy and rinse with sterile water.
Correct Answer: C
Rationale: Suctioning before removing the inner cannula (C) clears secretions and ensures airway patency. Alcohol-based solutions (A) are irritating, humidification (B) is needed, and removing the outer cannula (D) is unsafe.
The nurse is caring for a client with polycythemia vera. Which of the following actions should the nurse take? Select all that apply.
- A. Encourage increased fluid intake.
- B. Prepare the client for phlebotomy.
- C. Administer low-dose aspirin as prescribed.
- D. Teach the client to elevate the legs while sitting.
- E. Request a prescription for iron supplementation.
Correct Answer: A, B, C
Rationale: Increased fluids (A), phlebotomy (B), and aspirin (C) manage polycythemia vera by reducing blood viscosity and clotting risk. Leg elevation (D) is irrelevant, and iron supplementation (E) worsens the condition.
A nurse is reinforcing teaching to a client that breastfeeds who has been diagnosed with mastitis of the right breast. Which of the following instructions should be included? Select all that apply.
- A. Cease breastfeeding from right breast
- B. Increase oral fluid intake
- C. Reduce frequency of feeds to every 8 hours in right breast
- D. Take ibuprofen as needed for pain
- E. Use a tight-fitting underwire bra 24 hours per day
Correct Answer: B, D
Rationale: Increased fluids (B) and ibuprofen (D) manage dehydration and pain. Ceasing breastfeeding (A) or reducing feeds (C) can worsen mastitis, and tight bras (E) may increase discomfort.
The nurse is teaching about nonsteroidal anti-inflammatory drugs (NSAIDs) to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions?
- A. Reporting joint stiffness in the morning
- B. Taking the medication 1 hour before or 2 hours after meals
- C. Using alcohol in moderation unless driving
- D. Continuing to take aspirin for short term relief
Correct Answer: B
Rationale: Taking the medication 1 hour before or 2 hours after meals. Taking the medication 1 hour before or 2 hours after meals will result in a more rapid effect.
The nurse is caring for a client who has a prescription for ampicillin 1.5 g IV in 100 mL of 0.9% sodium chloride to be administered over 30 minutes. The nurse has tubing with a drop factor of 15 available. How many gtts/min should the client receive? Record your answer using a whole number.
Correct Answer: 50
Rationale: Flow rate = (100 mL / 30 min) x (15 gtts/mL) = 50 gtts/min (A).