Nokea
The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?
- A. Diet pattern
- B. Mobility
- C. Fluid intake
- D. Sexual function
Correct Answer: D
Rationale: Sexual function is not directly related to bowel and bladder retraining, unlike diet, mobility, and fluid intake.
You may also like to solve these questions
The nurse is caring for a client with scalding burns across the face, neck, upper half of the anterior chest, and entire right arm. Using the rule of nines, estimate the percentage of body burned.
- A. 18%
- B. 23%
- C. 32%
- D. 36%
Correct Answer: B
Rationale: Rule of nines: face/neck (4.5% head anterior), upper half anterior chest (4.5% anterior torso/2 = 2.25%), right arm (9%) = 4.5 + 2.25 + 9 = 23%.
An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals in the IV medication?
- A. Discard the solution and order a new bag
- B. Warm the solution
- C. Continue the infusion and document the finding
- D. Discontinue the medication
Correct Answer: A
Rationale: Crystals in IV fluorouracil indicate precipitation; the solution should be discarded to prevent administration errors.
A client who has been taking Coumadin (warfarin) was stabbed in the upper arm. His prothrombin time is over twice the normal amount. The nurse anticipates an order for
- A. fresh frozen plasma
- B. whole blood
- C. platelets
- D. packed red blood cells
Correct Answer: A
Rationale: Elevated prothrombin time indicates excessive anticoagulation. Fresh frozen plasma provides clotting factors to reverse warfarin’s effect and control bleeding.
Which client is at greatest risk for complications following abdominal surgery?
- A. A 68-year-old obese client with noninsulin-dependent diabetes
- B. A 27-year-old client with a recent history of urinary tract infections
- C. A 16-year-old client who smokes a half-pack of cigarettes per day
- D. A 40-year-old client who exercises regularly, with no history of medical conditions
Correct Answer: A
Rationale: Obesity and diabetes increase the risk of surgical complications like infection and poor wound healing.
A nurse performing a newborn assessment would expect what respiratory rate and heart rate as a normal finding?
- A. RR 15 breaths/minute, HR 72 beats/minute
- B. RR 35 breaths/minute, HR 96 beats/minute
- C. RR 46 breaths/minute, HR 153 beats/minute
- D. RR 68 breaths/minute, HR 137 beats/minute
Correct Answer: C
Rationale: Newborns have a respiratory rate of 30-60 breaths/min and heart rate of 120-160 beats/min. Option C (RR 46, HR 153) is within normal ranges.