Nokea
The charge nurse is performing safety rounds on clients in the nursing unit. Which observation by the charge nurse requires follow-up? A client with
- A. An indwelling urinary catheter bag secured to the bed frame.
- B. Delirium tremens having a peripheral vascular access device (VAD) inserted.
- C. Right-sided weakness with their cane on the left side of the bed.
- D. A belt restraint was applied and secured over the chest.
Correct Answer: C,D
Rationale: A cane on the left side for right-sided weakness is inaccessible, and a belt restraint over the chest is unsafe, risking respiratory compromise. Catheter bag placement and VAD in delirium tremens are appropriate.
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The nurse is inserting an indwelling urinary catheter in a male client. It would be appropriate for the nurse to inflate the catheter's balloon when
- A. Meeting resistance.
- B. As soon as urine is observed in the tubing.
- C. After advancing to the point of bifurcation.
- D. After fully advancing the length of the catheter.
Correct Answer: C
Rationale: The balloon should be inflated after advancing the catheter to the bifurcation (Y-connector), ensuring it is in the bladder. Inflating too early or fully advancing risks trauma or improper placement.
The nurse has attended a conference on intraoperative nursing interventions for the older adult. which of the following statements by the nurse would indicate the need for additional teaching?
- A. Warming devices should be used to prevent the client from developing hypothermia
- B. The client's head and feet should be covered during surgery
- C. Clients should be slid, not lifted into the proper position
- D. Providing extra padding for clients with decreased peripheral circulation is important
Correct Answer: C
Rationale: Sliding clients instead of lifting can cause shear injuries, particularly in older adults with fragile skin. Warming devices, covering extremities, and extra padding are appropriate to prevent hypothermia and protect pressure points, indicating correct understanding.
While scheduling a client for thoracentesis, the nurse understands which of the following is the most preferred position for the procedimiento?
- A. Sitting up, leaning over a bedside table, and feet supported on the ground or stool.
- B. The head of the bed flat with the patient lying on the unaffected side.
- C. Prone position with both arms extended above the head.
- D. The head of the bed elevated 45 degrees, and the patient lying on the affected side.
Correct Answer: A
Rationale: Sitting up and leaning forward maximizes lung expansion and pleural fluid access for thoracentesis. Other positions restrict access or increase complication risk.
The nurse is caring for a 4-year-old child who is being hospitalized due to complications from an autoimmune disorder, frequent infections, and a low white blood cell count. This child is very nervous about being in the hospital. Which intervention should the nurse implement to address this child's fears?
- A. Provide the child with a private room
- B. Encourage them to play with other children in the common area
- C. Advise the parents to only visit during visiting hours
- D. Allow the parents to stay as much as they'd like
Correct Answer: D
Rationale: Parental presence reduces fear in a hospitalized child, especially with immune compromise. A private room is ideal but not the focus, group play risks infection, and limited visits increase anxiety.
The nurse is caring for a client who is describing pain on their hand as 'throbbing and sharp.' Which type of pain is the client experiencing based on this sensory description?
- A. Somatic pain
- B. Visceral pain
- C. Ischemic pain
- D. Neuropathic pain
Correct Answer: A
Rationale: Throbbing and sharp pain describe somatic pain, arising from skin or musculoskeletal tissue. Visceral pain is dull, ischemic pain is aching, and neuropathic pain is burning or tingling.