Nokea
The nurse has inserted an indwelling urethral catheter in a male client. The nurse should secure the catheter tubing to the client's
- A. Inner thigh.
- B. Upper thigh.
- C. Upper abdomen.
- D. Knee
Correct Answer: B
Rationale: Securing the catheter to the upper thigh prevents tension and dislodgement while allowing mobility. Inner thigh risks irritation, upper abdomen is impractical, and knee restricts movement.
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The patient is experiencing post-operative tachycardia with low blood pressure. The nurse should be most concerned about which of the following surgical complications?
- A. The development of an infection
- B. Hemorrhage
- C. Wound dehiscence
- D. Hematoma
Correct Answer: B
Rationale: Tachycardia with low blood pressure suggests hemorrhage, a life-threatening complication requiring immediate attention. Infection, dehiscence, and hematoma are less acute.
The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct in identifying which of the following medications can increase the risk for falls? Select all that apply.
- A. naproxen
- B. alprazolam
- C. bumetanide
- D. verapamil
- E. allopurinol
- F. thiamine
Correct Answer: B,C,D
Rationale: Alprazolam (benzodiazepine) causes sedation and dizziness, bumetanide (diuretic) can cause orthostatic hypotension, and verapamil (calcium channel blocker) can cause hypotension, all increasing fall risk. Naproxen, allopurinol, and thiamine do not significantly contribute to falls.
The nurse observes a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Which of the following should the nurse assess in the patient?
- A. Pain
- B. Anxiety
- C. Depression
- D. Fluid volume deficit
Correct Answer: A
Rationale: Stooped gait, grimacing, and gasping suggest pain, requiring immediate assessment. Anxiety, depression, or fluid deficit are less likely based on these signs.
The nurse is caring for a client who has nausea related to prescribed chemotherapy treatments. The nurse should recommend that the client. Select all that apply.
- A. Consume foods and liquids at room temperature.
- B. Drink a large amount of fluid with meals.
- C. Consume foods without aromas
- D. Eat smaller portion sizes throughout the day.
- E. Delay taking the prescribed antiemetic until the nausea is severe.
Correct Answer: A,C,D
Rationale: Room-temperature foods, low-aroma foods, and smaller portions reduce nausea. Large fluid intake with meals worsens nausea, and antiemetics should be taken proactively.
A nurse is caring for a client with pneumonia who is in bilateral wrist restraints for removing multiple peripheral vascular access devices. Upon assessment, the client developed agitation and increased confusion. The nurse should take which priority action?
- A. Obtain vital signs
- B. Release restraints and provide range of motion
- C. Auscultate lung sounds
- D. Assess skin integrity under each restraint
Correct Answer: A
Rationale: Obtaining vital signs is the priority to assess for physiological causes of agitation and confusion, such as hypoxia or fever.