Nokea
Perineal care to a female client by the nurse can be performed:
- A. Without gloves, pouring water from a sterile bottle
- B. Without gloves, having the client perform all care
- C. With gloves, washing the perineal area from front to back
- D. With gloves, washing the perineal area from back to front
Correct Answer: C
Rationale: Perineal care requires gloves and washing from front to back to prevent bacterial contamination of the urethra, ensuring infection control.
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Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:
- A. tolerance.
- B. constipation.
- C. sedation.
- D. addiction.
Correct Answer: D
Rationale: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.
A client is to have an enema to reduce flatus. The enema tube should be inserted:
- A. 4 inches.
- B. 6 inches.
- C. 2 inches.
- D. 8 inches.
Correct Answer: A
Rationale: Enema tubing must be passed beyond the internal sphincter. Two inches is not far enough to pass the internal sphincter. Both 6 and 8 inches are too far and might cause trauma to the bowel.
A spinal change occurring with pregnancy that alters mobility is:
- A. scoliosis.
- B. kyphosis.
- C. lordosis.
- D. ankylosing spondylitis.
Correct Answer: C
Rationale: The spinal change occurring with pregnancy is lordosis. This occurs due to the weight of the enlarging uterus and the affect of gravity.
The client with an indwelling urinary catheter requires discharge teaching. Which interventions should the nurse include in the teaching plan? Select all that apply.
- A. Plan to change the urinary catheter once a week.
- B. Cleanse the perineal area daily with soap and water.
- C. Secure the catheter tubing to the thigh with tape.
- D. Avoid showering while the catheter is in place.
- E. Perform hand hygiene before and after catheter care.
Correct Answer: B,C,E
Rationale: B: Daily cleansing with soap and water prevents infection. C: Securing the catheter reduces trauma. E: Hand hygiene minimizes infection risk. A: Monthly changes are recommended unless blockage occurs. D: Showering is safe if the client's condition allows.
The experienced nurse observes the student nurse caring for the client with the wet plaster cast illustrated. Which conclusion by the experienced nurse is correct?
- A. The student should not be touching the plaster cast because it is wet.
- B. The student should be using a pillow to lift the client's casted extremity.
- C. The student is correctly handling a wet plaster cast with the palms.
- D. The student should be using fingers and not the palms to handle the cast.
Correct Answer: C
Rationale: C: Using palms prevents indentations in wet casts. A: Wet casts can be touched to reposition. B: Pillows limit inspection of the cast underside. D: Fingers cause pressure points.