Nokea
The nurse is caring for a postpartum client 2 hours post-delivery who is unable to void. Which of the following nursing interventions should be considered initially?
- A. Insert a straight catheter for residual
- B. Encourage oral intake of fluids
- C. Check perineum for swelling or hematoma
- D. Palpate bladder for distention and position
Correct Answer: D
Rationale: Palpating the bladder assesses for distention, which may indicate urinary retention, guiding further interventions without immediately resorting to invasive measures.
You may also like to solve these questions
Vitamin K is administered to the newborn shortly after birth for which of the following reasons?
- A. To stop hemorrhage
- B. To treat infection
- C. To replace electrolytes
- D. To facilitate clotting
Correct Answer: D
Rationale: Vitamin K is given to newborns to facilitate clotting, preventing hemorrhagic disease due to low vitamin K levels.
A new graduate nurse has an argument with a coworker regarding how the medication cart should be organized. The nurse asks his coworker to step into the break room to discuss their disagreement. This is an example of what type of conflict management?
- A. competing
- B. confronting
- C. accommodating
- D. avoiding
Correct Answer: B
Rationale: Confronting involves directly addressing conflict through discussion, as the nurse does by initiating a private conversation.
The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before administering medication. Which method is best for identifying patients using two patient identifiers?
- A. Take the medication administration record (MAR) to the room and compare it with the name and medical number recorded on the armband.
- B. Compare the medication administration record (MAR) with the client's room number and name on the armband.
- C. Request that a family member identify the client and then ask the client to state his name.
- D. Ask the client to state his full name and then to write his full name.
Correct Answer: A
Rationale: Comparing the MAR with the client's armband name and medical number ensures accurate identification using two reliable identifiers.
The physician has ordered that a 132-pound client with increased intracranial pressure receive 0.5 g of mannitol per kg in an IV solution. How many grams should be in the total mannitol dose? Record your answer using a whole number.
Correct Answer: 30
Rationale: Weight = 132 lb/ 2.2 = 60 kg. Dose = 0.5 g/kg X 60 kg = 30 g.
The nurse is seeing a client in the clinic who has shingles (herpes zoster). The client is concerned about spreading the disease to others. How should the nurse respond?
- A. It is only possible to have one episode of the disease.
- B. Persons with leukemia are at higher risk.
- C. Persons of all ages should receive the zoster vaccine (Zostavax).
- D. Persons between 30 and 40 years old are at high risk.
Correct Answer: B
Rationale: Shingles is contagious to immunocompromised individuals, such as those with leukemia, via contact with active lesions. The vaccine is recommended for older adults, not all ages, and recurrence is possible.