Nokea
An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?
- A. Blood clots
- B. Ecchymotic areas
- C. Jaundice
- D. Infection
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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During a urethral catheterization on a female, where would the healthcare provider observe the urethral meatus after separating the labia?
- A. Between the vaginal orifice and the anus.
- B. Between the clitoris and the vaginal orifice.
- C. Just above the clitoris.
- D. Within the vaginal canal.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client is being instructed on the proper use of a metered-dose inhaler. Which instruction should be provided to ensure the optimal benefits from the drug?
- A. Fill your lungs with air through your mouth and then compress the inhaler.
- B. Compress the inhaler while slowly breathing in through your mouth.
- C. Compress the inhaler while inhaling quickly through your nose.
- D. Exhale completely after compressing the inhaler and then inhale.
Correct Answer: B
Rationale: The correct technique for using a metered-dose inhaler involves compressing the inhaler while slowly breathing in through the mouth. This method helps ensure that the medication reaches deep into the lungs, allowing for optimal bronchodilation effect. Inhaling quickly through the nose or filling the lungs with air before compressing the inhaler are not recommended techniques for using a metered-dose inhaler effectively.
During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?
- A. Provide information about the hours and location of the chapel
- B. Document the statement in the client's spiritual assessment
- C. Invite the client to a healing service for people of all religions
- D. Offer to contact a spiritual advisor of the client's choice
Correct Answer: B
Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care.
When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?
- A. Place a sterile drape under the client's buttocks.
- B. Instruct the client to inhale and then exhale slowly.
- C. Discard the gloves and apply new sterile gloves.
- D. Apply a sterile lubricant to the end of the catheter.
Correct Answer: D
Rationale: After testing the catheter balloon for patency, the nurse should proceed to apply a sterile lubricant to the end of the catheter. This lubrication helps facilitate the insertion of the catheter smoothly. Placing a sterile drape under the client's buttocks should have been done prior to this step. Discarding the gloves and applying new sterile gloves is not necessary at this point in the procedure. Instructing the client to inhale and exhale slowly is not part of the immediate steps for inserting an indwelling urinary catheter.
A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?
- A. The client's respiratory rate is 14 breaths per minute.
- B. The client's oxygen saturation is 92%.
- C. The client reports shortness of breath.
- D. The client's respiratory rate is 24 breaths per minute.
Correct Answer: C
Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A), oxygen saturation of 92% (B), and respiratory rate of 24 (D) are not as immediately concerning as they may still fall within acceptable ranges for a client with COPD.