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The nurse enters the room of a client with dementia and observes the client grimacing while pulling at the indwelling urinary catheter. The nurse notes blood trickling from the urinary meatus and pink-tinged urine in the urinary drainage bag. It would be a priority for the nurse to
- A. obtain a urine specimen for urinalysis
- B. deflate the balloon of the urinary catheter
- C. remove the urinary catheter in a single swift motion
- D. use sterile gauze to absorb the blood around the meatus
Correct Answer: B
Rationale: Blood and grimacing suggest trauma or irritation from the catheter. Deflating the balloon allows safe removal to prevent further injury, pending provider orders.
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A 6-year old is admitted with a diagnosis of childhood autism. Which behavior is most typical of the child with autism?
- A. A willingness to talk to strangers
- B. A disinterest in inanimate objects
- C. Engaging in ritualistic behavior
- D. A dislike of music
Correct Answer: C
Rationale: Children with autism often engage in ritualistic or repetitive behaviors, such as specific routines or movements, as a hallmark of the condition. Choice A is incorrect because children with autism typically have social communication difficulties and are less likely to engage with strangers. Choice B is incorrect as they may show intense interest in specific inanimate objects. Choice D is incorrect as music preference varies and is not a defining characteristic.
A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? Select all that apply.
- A. How to take own pulse
- B. Monitoring daily weight
- C. Need for monthly International Normalized Ratio testing
- D. Need to increase foods high in potassium
- E. Reduction of sodium in diet
- F. Use of home oxygen
Correct Answer: A,B,E
Rationale: Taking pulse (A), monitoring weight (B), and reducing sodium (E) help manage heart failure by tracking symptoms, detecting fluid retention, and preventing exacerbation.
The nurse is caring for a 31-year-old gravida 2, para 1 woman who is in labor. The woman calls the nurse and says, 'My water has broken and I feel something between my legs.' The nurse looks and sees a loop of umbilical cord at the vaginal outlet. After signaling for help, what should the nurse do?
- A. Try to replace the cord with a sterile gloved hand
- B. Place the mother in knee-chest position
- C. Quickly apply manual pressure on the fundus
- D. Expect a rapid vaginal delivery
Correct Answer: B
Rationale: Knee-chest position relieves pressure on the prolapsed umbilical cord, maintaining fetal oxygenation until emergency delivery. Replacing the cord or pressing the fundus worsens the situation.
The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?
- A. Activate a rapid response team
- B. Ask the unlicensed assistive personnel to take vital signs and report back
- C. Direct the client's primary nurse to examine the client
- D. Personally go and auscultate the client's lungs
Correct Answer: C
Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.
During the admission bath, the nurse notes a region of impaired skin under a large sacral dressing. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Discusses the client's need for a nutrient-rich, high-calorie diet with the dietician
- B. Documents the impaired skin as an unstageable pressure injury in the client's medical record
- C. Gently cleanses the impaired skin with normal saline and pats the area dry with gauze
- D. Places a hydrophilic dressing over the impaired skin after performing wound care
- E. Repositions the client frequently and avoids putting pressure on the impaired skin
Correct Answer: A,C,D,E
Rationale: A nutrient-rich diet (A) supports wound healing. Cleansing with saline (C) prevents infection. A hydrophilic dressing (D) promotes a moist healing environment. Frequent repositioning (E) reduces pressure on the impaired skin.