Nokea
In cleansing the perineal area around the site of catheter insertion, the nurse would:
- A. Wipe the catheter toward the urinary meatus
- B. Wipe the catheter away from the urinary meatus
- C. Apply a small amount of talcum powder after drying the perineal area
- D. Gently insert the catheter another 1/2 inch after cleansing to prevent irritation from the balloon
Correct Answer: B
Rationale: Wiping away from the urinary meatus removes microorganisms from the insertion point, decreasing the risk of bladder infection. The other options increase infection risk or are inappropriate.
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A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
- A. Decreases the overall time of the labor process
- B. Prolongs the client's first stage of labor
- C. Decreases the time of the client's first stage of labor
- D. Prolongs the client's third stage of labor
Correct Answer: B
Rationale: The left occipital posterior position presents a larger fetal head diameter, increasing pressure on sacral nerves and prolonging the first stage of labor due to slower fetal descent.
A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?
- A. Gravida 4, para 2, ab 1
- B. Gravida 5, para 3, ab 1
- C. Gravida 5, para 4, ab 0
- D. Gravida 4, para 3, ab 0
Correct Answer: B
Rationale: The client has been pregnant five times (current pregnancy, two living children, one spontaneous abortion, one infant death), delivered three children (two living, one died), and had one abortion.
A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:
- A. Potassium-rich foods
- B. Tryptophan
- C. Tyramine
- D. Saturated fats
Correct Answer: C
Rationale: The client may need to avoid some potassium-rich foods (such as bananas, raisins, etc.). However, this is not because of the potassium content of these foods. Tryptophan is an essential amino acid that is present in high concentrations in animal and fish protein. The client will need to watch his dietary intake of tyramine. Tyramine is a by-product of the conversion of tyrosine to epinephrine. Tyramine is found in a variety of foods and beverages, ranging from aged cheese to caffeine drinks. Ingestion of tyramine-rich foods while taking a MAO inhibitor may lead to an increase in blood pressure and/or a life-threatening hypertensive crisis. To maintain a healthy lifestyle, restriction of dietary saturated fats is advisable.
A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:
- A. I understand your concern and will assist you with a referral.'
- B. Try not to worry because you will just upset your child.'
- C. Just ignore the behavior and it should disappear by age 8.'
- D. This is appropriate behavior for a preschooler and should not be a concern.'
Correct Answer: D
Rationale: This is normal for a preschooler, and a referral is not appropriate. Telling a parent not to worry is unhelpful. This response does not address the mother's concern. This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. This behavior is normal development for a preschooler.
A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:
- A. Excoriation
- B. Dehiscence
- C. Decortication
- D. Evisceration
Correct Answer: D
Rationale: Evisceration occurs when the incision separates and the contents of the cavity spill out.