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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The nurse is explaining the effects of cocaine abuse to a pregnant client. Which of the following must the nurse understand as a basis for teaching?
- A. Cocaine use can cause fetal growth retardation
- B. The drug has been linked to neural tube defects
- C. Newborn withdrawal generally occurs immediately after birth
- D. Breast feeding promotes positive parenting behaviors
Correct Answer: A
Rationale: Cocaine is vasoconstrictive, and this effect in the placental vessels causes fetal growth retardation.
The nurse is reinforcing instructions to a client at 34 weeks gestation who is preparing to travel by airplane. Which of the following instructions are appropriate? Select all that apply.
- A. Avoid getting up during the flight unless you need the restroom.
- B. Carry a copy of your most up-to-date prenatal record
- C. Increase fluid intake before and during the flight
- D. Secure the lap belt below the abdomen and across your hips when seated
- E. Wear compression stockings and loose-fitting clothing
Correct Answer: B,C,D,E
Rationale: Pregnant travelers should carry prenatal records for emergencies, stay hydrated to prevent dehydration, secure the lap belt safely, and wear compression stockings to reduce thrombosis risk. Avoiding movement increases clot risk, so periodic walking is recommended.
Medication administration record
Allergies: No Known Allergies
Sliding scale blood glucose levels, regular insulin dose
<150 mg/dL (<8.3 mmol/L), O units
150-199 mg/dL (8.3-11.0 mmol/L), 2 units
200-249 mg/dL (11.1-13.8 mmoV/L), 4 units
250-299 mg/dL (13.9-16.6 mmol/L), 6 units
≥300 mg/dL (≥16.7 mmol/L), 8 units and notify health care provider
A client with type 1 diabetes has a prescription for 30 units of insulin glargine at bedtime. Fingerstick blood glucose measurements are prescribed before meals and at bedtime with regular insulin based on a sliding scale. At 9 PM, the client's blood glucose measurement is 180 mg/dL (10.0 mmol/L). What action should the nurse take?
- A. Administer 30 units of glargine; give the client a snack, then administer 2 units of regular insulin
- B. Administer 30 units of glargine and 2 units of regular insulin in 2 different injections
- C. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the glargine first
- D. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the regular insulin first
Correct Answer: B
Rationale: The sliding scale indicates 2 units of regular insulin for a glucose of 180 mg/dL. Glargine, a long-acting insulin, should be given as prescribed (30 units). Glargine cannot be mixed with regular insulin in the same syringe due to differing pH levels, so separate injections are required.
A client with tuberculosis has an order for Rifadin (rifampin). What vitamin is usually given with rifampin?
- A. Thiamine
- B. Pyridoxine
- C. Folic acid
- D. Cyanocobalamin
Correct Answer: B
Rationale: Pyridoxine (vitamin B6) is given with rifampin to prevent peripheral neuropathy, a side effect. Other vitamins are not typically associated with rifampin therapy.
Prior to discharge from the postanesthesia care unit following a vein stripping of the left leg, the nurse should tell the client to:
- A. apply heat to the affected leg for 10 minutes out of every hour for the next 24 hours.
- B. sit with the legs up or walk but avoid prolonged standing and sitting with the feet down.
- C. avoid weight bearing on the affected leg for the next week.
- D. remove the compression bandages after 24 hours.
Correct Answer: B
Rationale: Elevating legs or walking promotes venous return, while avoiding prolonged standing/sitting prevents stasis post-vein stripping. Heat, non-weight bearing, and early bandage removal are not recommended.