Nokea
The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply
- A. Provide a low-stimulation environment
- B. Maintain bed rest
- C. Give antihypertensive medication.
- D. Administer betamethasone
- E. Monitor intake and output hourly
- F. Obtain a 24-hr urine specimen
- G. Perform a vaginal examination every 12 hr
Correct Answer: A, B, C, D, E, F
Rationale: Correct Answer: A, B, C, D, E, F
Rationale:
A: Providing a low-stimulation environment promotes rest and reduces stress.
B: Maintaining bed rest may be necessary for certain conditions to prevent complications.
C: Giving antihypertensive medication helps control blood pressure.
D: Administering betamethasone can be part of the treatment plan for certain conditions.
E: Monitoring intake and output hourly helps assess fluid balance and kidney function.
F: Obtaining a 24-hr urine specimen is a common diagnostic test to assess kidney function.
Summary:
Choice G is incorrect as performing vaginal examinations every 12 hours is unnecessary and invasive.
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A nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?
- A. Perform the cleansing procedure with a fresh swab two times
- B. Pick up the catheter 13 cm (5 in) from its tip
- C. Cleanse the tip of the penis in a side-to-side motion
- D. Lift the penis so that it is perpendicular to the client's body
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps in straightening the urethra, making it easier to insert the catheter. Lifting the penis perpendicular to the body also reduces the risk of trauma or injury during catheterization.
A, B, and C are incorrect because performing the cleansing procedure two times with a fresh swab, picking up the catheter 13 cm from its tip, and cleansing the tip of the penis in a side-to-side motion are not recommended practices and may increase the risk of contamination or injury.
A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss?
- A. Reviewing information about support groups for individuals who have had a stroke
- B. Obtaining an alert system to get help in case of a fall
- C. Providing information about available transportation resources
- D. Choosing an agency to provide home physical therapy
Correct Answer: B
Rationale: The correct answer is B: Obtaining an alert system to get help in case of a fall. This is the priority because the client's left-sided weakness puts them at risk for falls, which can have serious consequences. Having an alert system ensures they can get immediate help if a fall occurs, potentially preventing injuries or complications. Reviewing support groups (A) can be beneficial but is not as urgent. Providing transportation resources (C) and choosing a home physical therapy agency (D) are important but do not address the immediate safety concern of potential falls.
A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine is known to potentially cause liver injury. Monitoring liver function tests is crucial to detect any signs of liver damage early on. Kidney function tests (B), hemoglobin and hematocrit (C), and serum sodium and potassium (D) are not directly associated with atomoxetine use in ADHD. Monitoring liver function is the priority in this case.
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
- A. A noncoring needle
- B. An angiocatheter
- C. A butterfly needle
- D. A 25 gauge needle
Correct Answer: A
Rationale: The correct answer is A: A noncoring needle. This type of needle is specifically designed for accessing implanted venous access ports as it minimizes damage to the port septum, reducing the risk of infection and catheter damage. The noncoring needle has a special tip that creates a clean puncture without coring (cutting) the septum, ensuring proper access without compromising the integrity of the port.
Summary of why the other choices are incorrect:
B: An angiocatheter is not recommended for accessing venous access ports as it is not designed for this purpose and can cause damage to the port.
C: A butterfly needle is not suitable for accessing venous access ports as it can cause coring of the septum and increase the risk of infection.
D: A 25 gauge needle is too small and not suitable for accessing implanted venous access ports as it may not provide adequate flow rates and can lead to difficulty in accessing the port.
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chills
Correct Answer: B: Mastitis; A, C, D: Both
Rationale: The correct answer is B: Painful, tender breast - consistent with mastitis. Mastitis is an infection of the breast tissue, causing pain and tenderness. A: Foul-smelling lochia can be seen in both mastitis and endometritis. C: Temperature can be elevated in both conditions due to infection. D: Chills can also be present in both mastitis and endometritis as a response to infection. The other choices are left blank as they do not specifically align with either mastitis or endometritis in terms of assessment findings.