Nokea
The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?
- A. First voided specimen in the morning.
- B. A clean catch specimen.
- C. Any specimen voided after drinking adequate fluids.
- D. A 24-hour specimen.
Correct Answer: B
Rationale: A clean catch specimen minimizes contamination, providing accurate results for diagnosing urethritis, unlike other methods.
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Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?
- A. Watch for shortness of breath which may indicate a fat embolus.
- B. Begin range of motion exercises within the first 24 hours.
- C. Apply ice intermittently for the first 24 hours.
- D. After edema subsides, apply heat continuously.
Correct Answer: C
Rationale: Intermittent ice reduces swelling and pain in acute soft tissue injuries, prioritizing over other instructions.
While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?
- A. Appearance of the skin on the client's legs.
- B. Altered posture and balance during ambulation.
- C. Presence of bilateral femoral pulses.
- D. Signs of old and new ecchymosis.
Correct Answer: A
Rationale: Assessing skin appearance for signs of neuropathy supports hair loss as a diabetes complication.
A young adult client involved in a minor motor vehicle collision three weeks ago reports having a headache, blurred vision, vertigo, and nausea. The client's vital signs are within normal limits, and a nutrition history reveals that the client is eating very little because of being concerned about paying for car repairs. Priority nursing care should be based on which nursing problem?
- A. High risk for injury related to increased intracranial pressure.
- B. Alteration in comfort related to motor vehicle collision.
- C. Alteration in nutrition related to poor dietary intake.
- D. Anxiety related to unknown outcome of automobile repairs.
Correct Answer: A
Rationale: Symptoms suggest increased intracranial pressure, a serious post-collision complication, prioritizing over comfort or nutrition.
The nurse is evaluating a client's symptoms, and formulates the nursing problem, 'High risk for injury due to potential urinary tract infection.' Which symptoms indicate the need for this nursing problem?
- A. Straining on urination and nocturia
- B. Azotemia and anorexia.
- C. Hematuria and proteinuria.
- D. Fever and dysuria.
Correct Answer: D
Rationale: Fever and dysuria are classic UTI symptoms, indicating a risk for serious complications like pyelonephritis or sepsis. Other options suggest urinary issues but are less directly linked to injury risk.
A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?
- A. Increase the client's oxygen to 6 liters/minute.
- B. Obtain a stat arterial blood gas.
- C. Lower the bed to a semi-Fowler's position.
- D. Encourage the client to use pursed-lip breathing.
Correct Answer: B
Rationale: A stat arterial blood gas evaluates oxygenation and ventilation, guiding treatment for acute dyspnea, prioritizing over oxygen adjustment or positioning.