Nokea
The nurse has a pre-op order to insert a Foley catheter in a male client. The catheter should be inserted:
- A. 1-2 inches
- B. 3-4 inches
- C. 5-6 inches
- D. 7-9 inches
Correct Answer: D
Rationale: In males, a Foley catheter is inserted 7-9 inches to reach the bladder, ensuring proper placement without trauma.
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The nurse is to suction a client. What action is essential prior to inserting the suction catheter?
- A. Clear the mouth and throat of secretions.
- B. Lower the head of the bed.
- C. Oxygenate the client.
- D. Check the suction pressure.
Correct Answer: C
Rationale: Pre-oxygenation prevents hypoxia during suctioning, a critical step. Clearing secretions, lowering the bed, or checking pressure are secondary.
The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include
- A. formula or breast milk
- B. broth and tea
- C. rice cereal and apple juice
- D. gelatin and ginger ale
Correct Answer: A
Rationale: The usual diet for a young infant should be followed.
An 18-month-old is brought by her father to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry.
Which of the following comments by the nurse is the MOST appropriate?
- A. Don't cry. It will be better if you try to behave.'
- B. I know you are frightened. It will be over with soon.'
- C. A big girl like you shouldn't cry. It's only going to hurt a little.'
- D. Please stop crying. There is nothing to be afraid of.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication (1) nontherapeutic, doesn't respond to feeling tone and tells child what to do (2) correct-doesn't minimize child's reaction, responds to feeling tone (3) nontherapeutic, minimizes child's reaction (4) nontherapeutic, minimizes child's reaction, should indicate it is OK to feel afraid
The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?
- A. Central venous pressure reading of 11
- B. Respiratory rate of 22
- C. Pulse rate of 48 BPM
- D. Blood pressure of 144/92
Correct Answer: C
Rationale: One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse, and cardiac arrest (this drug should never be administered without continuous EKG monitoring).
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Syndeham's chorea?
- A. Irregular movements of the arms and legs and facial grimacing
- B. Painless swellings over the surface of the joints
- C. Faint areas of red demarcation over the back
- D. Swelling and inflammation of the joints
Correct Answer: A
Rationale: Syndeham's chorea is characterized by irregular, involuntary movements and facial grimacing, so A is correct. Answers B, C, and D describe other rheumatic fever symptoms but not chorea.