Nokea
The nurse is assigned a male client with a long-term in-dwelling catheter for incontinence. The nurse plans on performing which of the following to prevent complications?
- A. perform perineal care using sterile technique
- B. irrigate daily with 60 cc normal saline
- C. restrict fluids to 1,500 cc/day
- D. stabilize the catheter on the abdomen
Correct Answer: D
Rationale: Stabilizing the catheter prevents traction and urethral trauma. Perineal care uses clean technique, routine irrigation is unnecessary, and fluid restriction is inappropriate.
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The nurse is caring for a client with rheumatoid arthritis. The nurse knows that the client's symptoms will be most improved by:
- A. Taking a warm shower upon awakening
- B. Applying ice packs to the joints
- C. Taking two aspirin before going to bed
- D. Going for an early morning walk
Correct Answer: A
Rationale: A warm shower reduces morning stiffness in rheumatoid arthritis by improving joint mobility and reducing inflammation.
Which of the following statements reflects Kohlberg's theory of the moral development of the preschool-age child?
- A. Obeying adults is seen as correct behavior.
- B. Showing respect for parents is seen as important.
- C. Pleasing others is viewed as good behavior.
- D. Behavior is determined by consequences.
Correct Answer: D
Rationale: Kohlberg's preconventional stage for preschoolers involves moral decisions based on consequences, such as avoiding punishment or gaining rewards.
The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply.
- A. prepare to administer IV fluids
- B. notify the health care provider
- C. order a mechanical soft diet for the client
- D. administer the next dose of lithium when it is due
- E. observe the client for confusion and slurred speech
Correct Answer: A, B, E
Rationale: A lithium level of 2.2 mEq/L indicates toxicity (therapeutic range: 0.6–1.2 mEq/L). The nurse should prepare IV fluids, notify the provider, and monitor for symptoms like confusion and slurred speech. A soft diet is unnecessary, and the next dose should be held.
The nurse is caring for a patient with a colostomy. The patient asks, 'Will I ever be able to swim again?' The nurse's best response would be:
- A. Yes, you should be able to swim again, even with the colostomy.'
- B. You should avoid immersing the colostomy in water.'
- C. No, you should avoid getting the colostomy wet.'
- D. Don't worry about that. You will be able to live just like you did before.'
Correct Answer: A
Rationale: Swimming is possible with a colostomy if proper precautions, like a waterproof seal, are used to protect the stoma.
A nurse is working in an endoscopy recovery area. Many of the clients are administered midazolam (Versed) to provide conscious sedation. Which medication is important to have available as an antidote for Versed?
- A. Diazepam (Valium)
- B. Naloxone (Narcan)
- C. Flumazenil (Romazicon)
- D. Florinef (Fludrocortisone)
Correct Answer: C
Rationale: Flumazenil (Romazicon) is the antidote for benzodiazepines like midazolam, reversing sedation or overdose. Naloxone is for opioids, and the others are unrelated.