Nokea
The nurse is caring for a client with an indwelling urethral catheter. Which of the following actions should the nurse take? Select all that apply.
- A. Empty drainage bag when 1/2 full.
- B. Provide perineal hygiene using mild soap and hot water.
- C. Ensure tubing is clipped onto the edge of the linens.
- D. Wear sterile gloves while cleaning the urinary meatus.
- E. Clean catheter starting at meatus and moving downward while holding it securely.
Correct Answer: A,E
Rationale: Emptying the bag when half full prevents reflux, and cleaning from the meatus downward avoids contamination. Hot water is too harsh, clipping tubing risks tension, and clean gloves suffice for cleaning.
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The nurse is teaching at an interdisciplinary conference focused on age-related changes. Which of the following are expected in the older adult? Select all that apply.
- A. Fatty tissue is redistributed
- B. Skin becomes less elastic
- C. Cardiac output increases
- D. Muscle mass increases
- E. Hormone production increases
- F. Visual and hearing acuity diminishes
Correct Answer: A,B,F
Rationale: Aging involves fat redistribution, less elastic skin, and diminished sensory acuity. Cardiac output, muscle mass, and hormone production decrease.
The nurse is planning care for a pediatric client being admitted with pulmonary tuberculosis (TB). Which of the following interventions should the nurse include in the client's plan of care?
- A. consult the infection control nurse
- B. room the client with an uninfected client 6 feet apart
- C. place the client with another client who has varicella in the shared airborne isolation room 6 feet apart
- D. place the client in a private room with monitored positive airflow
Correct Answer: A
Rationale: Consulting the infection control nurse ensures proper airborne precautions for TB. Cohorting or positive airflow is inappropriate.
The emergency department charge nurse was notified of a mass shooting at a nearby shopping mall. The nurse should take which action to prepare for the surge in clients? Select all that apply.
- A. Work to arrange timely discharge and admission for appropriate clients.
- B. Establish a holding area for discharged clients not able to go home.
- C. Modify the nurse/client ratio to accommodate the surge levels.
- D. Instruct staff to switch from electronic to paper documentation.
- E. Prepare to provide frequent updates to local media.
Correct Answer: A,B
Rationale: Timely discharges/admissions and a holding area optimize resources. Modifying nurse ratios, switching to paper documentation, or media updates are not primary actions.
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.
A nurse is caring for a 90-year-old client who has been bedridden at home for two weeks. Which of the following is not an expected finding due to immobility?
- A. A decrease in bone density
- B. Loss of short-term memory
- C. Atelectasis
- D. High serum calcium level
Correct Answer: B
Rationale: Immobility causes bone density loss, atelectasis, and high serum calcium due to bone resorption, but short-term memory loss is not directly related to immobility.