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The nurse is caring for a client who has just returned from surgery with an indwelling urinary catheter in place. What is the most important assessment for the nurse to make?
- A. Check for catheter patency
- B. Assess the color of the urine
- C. Measure the urine output
- D. Ensure the catheter tubing is secure
Correct Answer: C
Rationale: The most important assessment for the nurse to make in this situation is to measure the urine output. This assessment is crucial in monitoring kidney function and fluid balance after surgery. While checking for catheter patency is important, it is not as critical as measuring urine output. Assessing the color of the urine can provide some information about kidney function, but measuring output gives a more accurate assessment. Ensuring the catheter tubing is secure is essential to prevent dislodgement but is not the most critical assessment to make at this time.
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A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?
- A. Use oxygen at the highest flow rate tolerated.
- B. Do not smoke while using oxygen.
- C. Avoid wearing the oxygen during physical activity.
- D. Store oxygen tanks in a cool, dark place.
Correct Answer: B
Rationale: The most important instruction the nurse should provide to a client with COPD receiving home oxygen therapy is not to smoke while using oxygen. Smoking near oxygen can cause a fire or explosion due to the flammable nature of oxygen. Choice A is incorrect because using oxygen at the highest flow rate tolerated without medical supervision can be harmful. Choice C is the correct answer as wearing oxygen during physical activity can increase the risk of oxygen combustion. Choice D is not the most important instruction; while storing oxygen tanks properly is essential, the immediate safety concern is the risk of fire due to smoking near oxygen.
A client with a severe headache is being assessed by a nurse. What should the nurse do first?
- A. Administer pain relief medication
- B. Check the client's blood pressure
- C. Assess for associated symptoms such as nausea or photophobia
- D. Offer a quiet environment
Correct Answer: B
Rationale: When a client presents with a severe headache, the initial action should be to check their blood pressure. This step is crucial as it can help determine if the headache is related to hypertension or other cardiovascular issues. Administering pain relief medication should only be done after assessing the client's vital signs and confirming the cause of the headache. While assessing for associated symptoms like nausea or photophobia is important for a comprehensive evaluation, it should follow checking the blood pressure to address immediate concerns. Offering a quiet environment is indeed beneficial for the client's comfort, but it is not the priority when dealing with a severe headache.
The nurse is caring for a client with a chest tube after thoracic surgery. What is the most important assessment related to the chest tube?
- A. Ensure continuous bubbling in the water seal chamber
- B. Measure the amount of drainage every shift
- C. Keep the drainage system at the level of the chest
- D. Assess for subcutaneous emphysema around the insertion site
Correct Answer: D
Rationale: The most important assessment related to a chest tube after thoracic surgery is to assess for subcutaneous emphysema around the insertion site. Subcutaneous emphysema can indicate air leakage from the pleural space, which can lead to serious complications such as a pneumothorax. Ensuring continuous bubbling in the water seal chamber is not the most critical assessment as it is a normal finding in a chest drainage system. While measuring the amount of drainage is important to monitor the client's condition, it is not as crucial as assessing for subcutaneous emphysema. Keeping the drainage system at the level of the chest helps maintain proper function but is not the most critical assessment in this scenario.
A client is diagnosed with type 1 diabetes mellitus. Which instruction about insulin administration should the nurse emphasize?
- A. Rotate injection sites to prevent tissue damage
- B. Inject insulin into the same site to increase absorption
- C. Only use insulin pens
- D. Mix different types of insulin in the same syringe
Correct Answer: C
Rationale: The correct answer is to only use insulin pens. This is because insulin pens provide a convenient and accurate way to administer insulin. Rotating injection sites is important to prevent tissue damage and promote consistent insulin absorption, making choice A incorrect. Injecting insulin into the same site can lead to lipodystrophy and is not recommended, making choice B incorrect. Mixing different types of insulin in the same syringe can alter their action profiles and is generally not recommended, making choice D incorrect.
During a bed bath, the nurse observes that a client's IV site is red and swollen. What should the nurse do first?
- A. Discontinue the IV under physician's guidance
- B. Apply a warm compress to the site
- C. Notify the physician
- D. Document the appearance of the site and continue the bath
Correct Answer: C
Rationale: The correct first action when a nurse observes a red and swollen IV site during a bed bath is to notify the physician. This is crucial because prompt reporting allows for immediate intervention to prevent further complications. Discontinuing the IV (Choice A) should only be done under the physician's guidance to avoid any adverse effects and ensure proper care. Applying a warm compress (Choice B) may not address the underlying issue and could potentially worsen the situation if the cause is an infection or infiltration. Documenting the site's appearance and continuing the bath (Choice D) without immediate action might delay necessary treatment, leading to potential complications.