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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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The nurse is screening clients for those at risk for developing a pressure injury. At highest risk for developing a pressure injury is the client
- A. who had an open cholecystectomy and has a closed-wound drainage device
- B. who has a long leg cast and a decreased serum albumin level
- C. with dementia, peripheral artery disease, and constipation
- D. with quadriplegia, moist skin, and an elevated temperature
Correct Answer: D
Rationale: Clients with quadriplegia are at high risk due to immobility, which impairs circulation and increases pressure on skin. Moist skin increases the risk of skin breakdown, and elevated temperature may indicate infection or inflammation, further increasing risk.
The nurse is reinforcing teaching to an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply.
- A. Eating a high-protein snack at bedtime
- B. Limiting alcohol intake
- C. Losing weight
- D. Taking a mild sedative at bedtime
- E. Taking a nap during the day
- F. Taking modafinil at bedtime
Correct Answer: B,C
Rationale: Limiting alcohol (B) reduces airway relaxation, and losing weight (C) decreases airway obstruction, both directly alleviating sleep apnea symptoms.
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 newborn had a bowel resection with temporary colostomy for Hirschsprung disease. The practical nurse should alert the supervising registered nurse about which postoperative finding?
- A. Moderate amount of blood-tinged mucus from the stoma on postoperative day 2
- B. Small amount of non-formed stool in the colostomy bag on postoperative day 6
- C. Stoma bleeds a small amount during colostomy bag change on postoperative day 3
- D. Stoma is gray-tinged at the edges but pink at the center on postoperative day 5
Correct Answer: D
Rationale: A gray-tinged stoma suggests ischemia or poor perfusion, which is a critical finding requiring immediate reporting to assess for stoma viability.
The nurse is screening clients with major depressive disorder for those at risk for suicide. The nurse should recognize the client at highest risk for suicide is the client with
- A. substance use disorder who is married and participates in community programs
- B. Parkinson disease who is divorced and has recently become unemployed
- C. breast cancer who is married and is newly diagnosed with alcohol use disorder
- D. type 2 diabetes mellitus who is recently divorced and has 3 children
Correct Answer: B
Rationale: Recent unemployment and divorce are significant stressors that increase suicide risk, especially in a client with a chronic condition like Parkinson disease, which can exacerbate depressive symptoms.