Nokea
The nurse is inserting an indwelling urinary catheter for a female client. After inserting and advancing the catheter, the nurse notes no return of urine. Which of the following actions should the nurse take?
- A. Inform the health care provider that the client has a possible obstruction.
- B. Obtain a new kit and insert the catheter at a higher position in the perineal area.
- C. Leave the catheter in place and recheck for urine output in 30 minutes.
- D. Remove the catheter and reinsert it at a position higher than the initial insertion.
Correct Answer: D
Rationale: No urine return may indicate incorrect placement. Reinserting at a slightly different angle corrects this. Notifying the provider is premature, a new kit is unnecessary, and waiting 30 minutes delays care.
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The nurse is caring for an adult who had a cerebrovascular accident. The nurse gives the client a washcloth and encourages the client to wash her face. The client looks at the washcloth as though she does not know what to do with it. The nurse knows that this indicates that the client has which of the following?
- A. Apraxia
- B. Aphasia
- C. Agnosia
- D. Dysarthria
Correct Answer: C
Rationale: Agnosia is the inability to recognize objects, like a washcloth, despite intact sensory function, common post-CVA, unlike apraxia (motor planning), aphasia (language), or dysarthria (speech articulation).
Laboratory reference ranges
BUN
10-20 mg/dL
(3.6-7.1 mmol/L)
An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which of the following data obtained
by the practical nurse is most important to report to the registered nurse before the client receives the next dose?
- A. client reports tinnitus
- B. Blood pressure 104/60 mm Hg
- C. urine output of 400 mL since last dose
Correct Answer: A
Rationale: Tinnitus may indicate ototoxicity, requiring immediate reporting. Low BP and urine output are less urgent without context of medication.
The nurse is monitoring a client during the dwell time of a peritoneal dialysis cycle. Which of the following findings would require immediate follow-up?
- A. reports of intermittent nausea
- B. crackles in the lung bases bilaterally
- C. 1+ pitting edema of the ankles and feet bilaterally
- D. blood pressure of 108/88 mm Hg and heart rate of 72/min
Correct Answer: B
Rationale: Crackles suggest fluid overload, a serious dialysis complication. Nausea , mild edema , and normal BP/HR are less urgent.
The nurse is talking with a client with major depressive disorder who is receiving isocarboxazid. Which of the following statements by the client would be a priority to follow up?
- A. I am feeling fatigued at the end of most days.
- B. I have been experiencing constipation recently
- C. I have been gaining weight since I started taking the medication
Correct Answer: A
Rationale: Fatigue may indicate worsening depression or MAOI side effects, requiring urgent follow-up. Constipation and weight gain are common but less critical.
Laboratory Results
Glucose - Fasting
70–110 mg/dL
(3.9–6.1 mmol/L) 650 mg/dL
(36.1 mmol/L)
A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering?
- A. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours
- B. IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy
- C. IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L)
- D. IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure
Correct Answer: C
Rationale: 0.45% saline is appropriate for gastroenteritis to replace fluids. 0.9% saline bolus treats anaphylactic shock. Mannitol reduces intracranial pressure. A 1000 mL bolus for DKA is excessive; smaller boluses (e.g., 250-500 mL) are safer to avoid fluid overload.