Nokea
The nurse is caring for a client ordered a 24-hour urine specimen collection. What action should the nurse take after collecting the first specimen?
- A. Place it in a separate container and later add to the collection
- B. Discard the sample and then start the collection immediately thereafter
- C. Discard the sample and then start the collection for twelve hours
- D. Save it as part of the total urine collection
Correct Answer: B
Rationale: The first voided specimen is discarded to start the 24-hour collection fresh, ensuring accurate timing. Saving or partially collecting is incorrect.
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Item 1 of 1 • Assessment
Neurological: Alert and Oriented x 4; anxious affect
Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema
Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea
Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine
Musculoskeletal: Full range of motion in all extremities; steady gait
Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing.
Pain: Reports incision pain as a 3 based on a scale of 0-10.
• Vital Signs
Blood Pressure 119/75 mm Hg
Temperature 99° F (37° C)
Heart rate 90/min
Respiratory rate 17 breaths per minute
Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing
--------------based on the client’s------------------------
- A. paralytic ileus
- B. wound infection
- C. intractable pain
- D. integumentary assessment
- E. pain assessment
- F. gastrointestinal assessment
Correct Answer: A,F
Rationale: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups).
The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding.
Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
The nurse is discussing infection control practices in the nursing unit. Which client requires droplet precautions? A client with Select all that apply.
- A. Diagnosed with rubella.
- B. A new diagnosis of pharyngeal diphtheria.
- C. Receiving chemotherapy via an implanted port.
- D. Pulmonary tuberculosis receiving nebulizer treatments.
- E. A skin abscess that tested positive for Klebsiella.
Correct Answer: A,B
Rationale: Rubella and pharyngeal diphtheria require droplet precautions due to respiratory transmission. TB requires airborne, chemotherapy does not require isolation, and Klebsiella abscess requires contact precautions.
The following scenario applies to the next 1 items
Item 1 of 1
Nurses' Notes
Orders Current Medications Laboratory>
1700: 73-year-old male reports explosive, watery, foul-smelling diarrhea that started two days ago. The client reports intermittent abdominal cramping that occurs with watery diarrhea. He says his wife made him come in to get medical attention because he was starting to 'feel weak' and 'probably dehydrated.' The client was assessed to have: a sunken eye appearance, dry, flaky skin, and thready peripheral pulses. VS: Oral Temperature 98° F (36.7° C), pulse 86/minute, respirations 16/minute, blood pressure 113/68 mm Hg, oxygen saturation 96% on room air.
1725: Stool sample of foul-smelling diarrhea sent to the lab.
1830: Laboratory result received. Physician notified of results.
The nurse reviews the nurses' notes, orders, current medications, and laboratory data for a 73-year-old male with explosive, watery, foul-smelling diarrhea. Based on the clinical data, select five (5) nursing interventions the nurse should implement.
- A. Obtain a prescription for metronidazole
- B. Place a droplet precautions sign outside the room
- C. Educate the client to wash surfaces at home with bleach
- D. Remove the alcohol-based sanitizers from the room
- E. Request a prescription for a cleansing enema
- F. Encourage the intake of by mouth (PO) fluids
- G. Review hand hygiene measures with the client
Correct Answer: A,C,D,F,G
Rationale: Suspected C. difficile requires metronidazole, bleach cleaning, removal of alcohol-based sanitizers, fluid intake encouragement, and hand hygiene education. Droplet precautions and enemas are not indicated.
The nurse is caring for a client in pain. The nurse asks the client which level of pain he is in, and the client says it's 1 out of 10. The nurse notices that the client grimaces every time he moves. What is the nurse's most appropriate action?
- A. Administer analgesics to the client.
- B. Move on to other patients.
- C. Ask the client about his grimacing with every movement.
- D. Encourage the client to watch his favorite TV show.
Correct Answer: C
Rationale: Grimacing suggests pain despite the low rating, so further assessment clarifies the discrepancy. Administering analgesics, ignoring the issue, or distraction are premature.
The nurse is observing a student nurse wash their hands with soap and water. Which observation requires follow-up? The student nurse
- A. washes their hands using warm water.
- B. dries hands thoroughly from wrists to fingers with paper towel.
- C. wets their wrists and hands with fingers pointed downward.
- D. pushes wristwatch and long uniform sleeves above wrists.
Correct Answer: C
Rationale: Fingers should point upward during handwashing to ensure soap and water reach all surfaces effectively.