Nokea
The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse
- A. attaches the drainage tubing to a leg collection bag
- B. retracts the foreskin before applying the condom sheath
- C. assesses the condition of the penile skin prior to application
- D. leaves a 1- to 2-inch (2.5- to 5-cm) space at the tip of the condom
Correct Answer: B
Rationale: Retracting the foreskin before applying a condom catheter risks paraphimosis if not repositioned afterward, requiring intervention. Other actions are correct: attaching tubing, assessing skin, and leaving space prevent complications.
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A 6-month-old infant is being seen in the doctor's office. Which observation by the nurse should be brought to the physician's attention?
- A. The baby sits up but needs slight support.
- B. The baby was 7 lb at birth and now weighs 10 lb.
- C. The baby frequently drops objects and looks for them.
- D. The baby smacks her lips and drools.
Correct Answer: B
Rationale: A 6-month-old should double birth weight (14 lb expected for 7 lb); 10 lb suggests poor growth, requiring evaluation. Other findings are developmentally normal.
The nurse is caring for a client who had a total thyroidectomy. What should the nurse plan to observe the client for immediately after his return to the nursing care unit?
- A. Hoarseness
- B. Signs of hypercalcemia
- C. Loss of reflexes
- D. Mental confusion
Correct Answer: B
Rationale: Total thyroidectomy risks parathyroid gland damage, leading to hypocalcemia (not hypercalcemia). However, the question likely intends hypocalcemia signs (tetany, spasms), which are critical to monitor immediately post-surgery. Hoarseness, reflexes, or confusion are less urgent.
The nurse is reinforcing teaching about how to use a metered-dose inhaler to a 9-year-old with asthma. Place the nurse's instructions in the appropriate order. All options must be used.
- A. Exhale completely
- B. Deliver one puff of medication into spacer
- C. Place lips tightly around the mouth piece
- D. Rinse mouth with water
- E. Shake the inhaler and attach it to spacer
- F. Take a slow deep breath, and hold it for 10 seconds
Correct Answer: E,A,B,C,F,D
Rationale: The correct order is: 1) Shake the inhaler and attach it to spacer (prepares medication); 2) Exhale completely (clears lungs); 3) Deliver one puff into spacer (releases medication); 4) Place lips tightly around the mouthpiece (ensures delivery); 5) Take a slow deep breath, and hold it for 10 seconds (allows medication absorption); 6) Rinse mouth with water (prevents oral thrush).
An adult is admitted with Guillain-Barré syndrome. On day 3 of hospitalization, the client's muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in the nursing care plan at this time is to prevent which problem?
- A. Aspiration pneumonia
- B. Decubitus ulcers
- C. Bladder distention
- D. Hypertensive crisis
Correct Answer: A
Rationale: Difficulty swallowing increases aspiration risk, making aspiration pneumonia the priority. Other complications are secondary in this acute phase.
During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to
- A. increase fluids that are high in protein
- B. restrict fluids
- C. force fluids and reassess blood pressure
- D. limit fluids to non-caffeine beverages
Correct Answer: C
Rationale: Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.