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The nurse is inserting a urinary catheter in the client with urinary retention. During balloon inflation, the client reports pain. What is the nurse's best action?
- A. Withdraw the sterile water from the balloon and advance the catheter further.
- B. Continue inflating the balloon as this finding is expected during catheter insertion.
- C. Remove the catheter and reattempt insertion with a smaller urinary catheter.
- D. Reposition the catheter by rotating it slightly and continue to inflate the balloon.
Correct Answer: A
Rationale: A: Pain suggests the catheter is in the urethra, not the bladder; advancing after deflating corrects placement. B: Pain is abnormal and risks damage. C: Removal is unnecessary if advancement works. D: Rotating a partially inflated balloon could harm the urethra.
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The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?
- A. a 63-year-old female undergoing chemotherapy for breast cancer
- B. a 56-year-old female with dementia undergoing a swallow study
- C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
- D. a 45-year-old male recovering from a knee replacement under general anesthesia
Correct Answer: D
Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected. For other clients, less than 5 bowel sounds per minute is an abnormal finding.
The client reports pain in the right leg even though it was amputated. Which complementary therapy should the nurse use to control the phantom pain associated with the client's amputation?
- A. A small dose of alprazolam at 8-hour intervals in addition to prescribed oxycodone and acetaminophen q6h pm
- B. A high-fiber diet and 2000 mL fluid intake in 24 hours while taking hydromorphone at 4- to 6-hour intervals pm
- C. Progressive relaxation exercises three times daily in addition to use of a transdermal patch of fentanyl
- D. A local anesthetic as a nerve block in addition to prescribed long-acting oxycodone
Correct Answer: C
Rationale: C: Progressive relaxation is a complementary therapy that aids phantom pain relief with analgesics. A: Alprazolam is conventional, not complementary. B: Diet addresses opioid side effects, not pain. D: Nerve blocks are conventional medical interventions.
Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?
- A. Sleep Pattern Disturbances (related to arthritis)
- B. Fatigue (related to leg pain)
- C. Knowledge Deficit (regarding sleep hygiene measures)
- D. Sleep Pattern Disturbances (related to chronic leg pain)
Correct Answer: D
Rationale: The client's sleep pattern is directly disturbed by the chronic leg pain, which is secondary to the arthritis. This nursing diagnosis is the appropriate one to directly deal with comfort measures and the like.
The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?
- A. Assist the client to a sitting position at the edge of the bed.
- B. Have the client march in place for 30 seconds.
- C. Have the client raise his arms above his head.
- D. Ask the client the last time he fell.
Correct Answer: A
Rationale: The client should be assisted to a sitting position prior to standing. This action can prevent orthostatic hypotension. Marching in place and raising the client's arms above his head are not necessary prior to ambulation. While knowing about the client's last fall can be important, it is not the priority action before ambulating the client.
A nurse is assessing a patient in the ICU. The patient has the following signs: weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?
- A. Hypoglycemic patient
- B. Hyperglycemic patient
- C. Cardiac arrest
- D. End-stage renal failure
Correct Answer: B
Rationale: All of the clinical signs indicate a hyperglycemic condition.