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The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?
- A. Nasogastric tube (NGT)
- B. Bottle of sterile water
- C. Suction equipment
- D. Tracheostomy
Correct Answer: C
Rationale: Cheiloplasty is a surgical repair of a cleft lip, which can affect the infant’s ability to feed and maintain a clear airway. Suction equipment is essential at the bedside to clear secretions or blood from the oral cavity, preventing airway obstruction and ensuring airway patency. A nasogastric tube is not typically required unless feeding difficulties are severe. Sterile water is not a priority for immediate postoperative care, and a tracheostomy is not indicated for this procedure.
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The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). To prevent complications during and after the procedure, the nurse should assess the client's
- A. sensation in the lower extremities
- B. dentition
- C. grip strength
- D. peripheral vision
Correct Answer: B
Rationale: Assessing dentition is critical before ECT to identify loose teeth or dental appliances that could pose an airway risk during induced seizures. Sensation, grip strength, and peripheral vision are not directly related to ECT complications.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with droplet precautions? Select all that apply.
- A. Clostridium difficile
- B. Cryptococcal meningitis
- C. Mycoplasma pneumonia
- D. Haemophilus influenzae, type b pneumonia
- E. Rheumatic fever
- F. Varicella Zoster
- G. Scabies
Correct Answer: C,D
Rationale: Mycoplasma pneumonia and Haemophilus influenzae pneumonia require droplet precautions. Others require contact or standard precautions.
Which of the following responses should the nurse avoid when communicating with a client who has just received a poor prognosis? Select all that apply.
- A. My mother has the same thing.
- B. I'll sit with you for a while.
- C. I think you should try having surgery.
- D. Don't cry, everything is going to be okay.
- E. Do you have any questions for me right now?
Correct Answer: A,C,D
Rationale: Avoid personal anecdotes, medical advice, or minimizing emotions, as they dismiss the client’s feelings. Offering presence and open-ended questions are therapeutic.
The nurse is part of an infection control committee that is responding to an outbreak of norovirus in the long-term care facility. Which recommendation should the nurse make to prevent further transmission of this outbreak?
- A. Clients wear surgical masks while ambulating in the hallway.
- B. Replace boxes of clean gloves with sterile gloves.
- C. Review hand hygiene expectations with dietary staff.
- D. Screen visitors for any respiratory symptoms such as cough or fever.
Correct Answer: C
Rationale: Norovirus spreads via fecal-oral route, so reinforcing hand hygiene, especially among dietary staff, is critical. Masks, sterile gloves, and respiratory screening are less relevant.
The nurse is removing an indwelling urinary catheter
Item 1 of 1
Nurses Note
The removal of the client’s indwelling urinary catheter was attempted. Perineal hygiene was performed before the removal. The urine collection bag was emptied with 450 mL of clear, straw-colored urine. 2 mL of fluid was removed during the deflation of the balloon. Resistance was felt when the tubing was removed, and the client reported discomfort.
Drag words from the choices below to fill the blank in the following sentence. Prior to attempting to remove the catheter again, the nurse should--------------------------
- A. place a warm compress over the perineum
- B. cut the balloon inflation valve
- C. position the client at 45 degrees
- D. further deflate the catheter balloon
Correct Answer: D
Rationale: The amount of fluid removed from the balloon (this secures the catheter in place inside of the bladder) was inadequate. 10 mL of fluid is typically used to inflate the catheter balloon to keep it secure inside the bladder. The nurse should further deflate the catheter balloon by passively allowing the fluid to fill the syringe. The nurse may gently pull back on the syringe plunger if this does not work. By removing the residual volume, the nurse should then remove the catheter.
Cutting the balloon inflation valve would negate the closed system. Cutting the valve is not standard practice and should not be done. Positioning the client 45 degrees is not appropriate for discontinuing an indwelling urinary catheter. The correct approach for positioning a client to remove an indwelling catheter is having a male client supine and a female in the dorsal recumbent position.
Placing a warm compress over the perineum may give the client comfort, but this will not effectively troubleshoot the problem with the catheter. The issue is not with a bladder spasm, yet an indwelling urinary catheter that has not been entirely deflated.