Nokea
The nurse is inserting an indwelling urinary catheter for a female client. Which of the following actions should the nurse take? Select all that apply.
- A. Use the nondominant hand to gently spread the labia folds
- B. Apply sterile gloves and place the drape under the client's buttocks.
- C. Insert and advance the catheter 2 in (5 cm) and then inflate the balloon
- D. Place the client on the back with the knees flexed and hips rotated externally.
- E. Cleanse the labia majora and labia minora before cleansing the urinary meatus
Correct Answer: A,B,D
Rationale: Spreading labia aids visualization. Sterile gloves and drape maintain sterility. Proper positioning facilitates insertion. Advancing only 2 inches is insufficient (should be 5-7 cm) before balloon inflation. Cleansing should start with the meatus , not labia.
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The nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect?
- A. The parent cannot stay at the hospital due to potential job loss from absence
- B. The parent is in the process of a divorce and will soon be a single parent
- C. The parent is witnessed stealing food and drinks from the cafeteria
- D. The parent leaves the client's younger sibling to care for the client's newborn sibling
Correct Answer: D
Rationale: Leaving a young child to care for a newborn indicates inadequate supervision, supporting neglect. Job constraints , divorce , and stealing food suggest stress but not direct neglect.
The nurse reinforces discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder. The nurse advises the parent that the child might experience which side effects?
- A. Decreased blood pressure and growth delays
- B. Heart palpitations and weight gain
- C. Loss of appetite and restlessness
- D. Trouble sleeping and a dry cough
Correct Answer: C
Rationale: Methylphenidate commonly causes loss of appetite and restlessness . Hypotension , palpitations/weight gain , and cough are less typical.
Because a client is scheduled for a liver biopsy, the nurse should check to be sure that which laboratory test results have been received?
- A. Serum electrolytes
- B. Prothrombin time
- C. CBC with differential
- D. Serum creatinine
Correct Answer: B
Rationale: Liver biopsy carries a risk of bleeding due to the liver's vascular nature. Prothrombin time assesses clotting ability, critical to ensure the client can safely undergo the procedure without excessive bleeding risk. Electrolytes, CBC, and creatinine are less directly related to bleeding risk.
The nurse is about to medicate a client who is to have surgery today. The client says, 'I do not understand what the doctor is going to do,' and asks the nurse to explain specific details of the surgery. The client has already signed an operative permit. What is the best action for the nurse to take at this time?
- A. Attempt to answer the client's questions
- B. Notify the physician of the client's concerns prior to medicating the client
- C. Reassure the client that the physician is well respected and very competent
- D. Suggest that the client ask the physician her questions when in the operating room
Correct Answer: B
Rationale: The client's lack of understanding indicates a need for clarification before proceeding. Notifying the physician ensures informed consent is valid, delaying medication that may impair judgment.
The nurse is reinforcing teaching about breastfeeding to a postpartum client. Which statement by the client indicates a correct understanding of teaching?
- A. I will feed my baby for 5-10 minutes on each breast.
- B. I will hold my baby on their back with the head turned toward my breast.
- C. If I need to reposition my baby's latch, I will use my finger to break the suction first.
- D. The baby's mouth should grasp only the nipple, not the areola.
Correct Answer: C
Rationale: Breaking suction with a finger prevents nipple trauma. Short feeding times , lying on back , and nipple-only latch are incorrect.