Nokea
The nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 6 inches (15.2 cm), the nurse notes a small amount of urine in the tubing. Which of the following actions should the nurse take next?
- A. Measure the urine output.
- B. Immediately inflate the balloon.
- C. Secure the catheter tubing to the client's leg.
- D. Continue to advance the catheter to the bifurcation.
Correct Answer: D
Rationale: Advancing to the bifurcation (D) ensures proper placement in the bladder before inflating the balloon. Measuring output (A), inflating early (B), or securing (C) are premature.
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A client is being discharged after having a coronary artery bypass grafting x5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply.
- A. Report any itching, tingling, or numbness around your incisions
- B. Report any redness, swelling, warmth, or drainage from your incisions
- C. Soak incisions in the tub once a week, then clean with hydrogen peroxide and apply lotion
- D. Wash incisions daily with soap and water in the shower and gently pat them dry
- E. Wear an elastic compression hose on your legs and elevate them while sitting
Correct Answer: A, B, D
Rationale: Reporting sensory changes (A), signs of infection (B), and washing gently (D) promote healing. Soaking and peroxide (C) can disrupt healing, and compression hose (E) are not routinely needed.
A client with a panic disorder has a new prescription for Xanax (alprazolam). In teaching the client about the drug's actions and side effects, which of the following should the nurse emphasize?
- A. Short-term relief can be expected
- B. The medication acts as a stimulant
- C. Dosage will be increased as tolerated
Correct Answer: A
Rationale: Short-term relief can be expected. Xanax is a short-acting benzodiazepine useful in controlling panic symptoms quickly.
A parent brings her 3 month-old into the clinic, reporting that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment?
- A. increased temperature and lethargy
- B. restlessness and increased mucus production
- C. increased sleeping and listlessness
- D. diarrhea and poor skin turgor
Correct Answer: B
Rationale: This infant could be experiencing gastroesophageal reflux, or could be allergic to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present.
The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?
- A. Need for an eye examination
- B. Need for sunblock
- C. Risk for infection
- D. Risk for kidney injury
Correct Answer: C
Rationale: Methotrexate suppresses the immune system, significantly increasing the risk for infection (C). This is a critical teaching point to ensure the client takes precautions. Eye exams (A), sunblock (B), and kidney injury (D) are less directly associated with methotrexate's primary risks.
Laboratory reference ranges
Glucose (random) – newborn < 24 hours old
40-60 mg/dL
(2.2-3.3 mmol/L)
The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply.
- A. respirations of 56 breaths per minute
- B. capillary glucose of 60 mg/dL (3.3 mmol/L)
- C. holosystolic murmur auscultated at fourth intercostal space
- D. single transverse crease across palm of the hand
- E. white papules on bridge of the nose
Correct Answer: A, B, E
Rationale: Respirations of 56 (A), glucose of 60 mg/dL (B), and white papules (milia) (E) are normal in neonates. A holosystolic murmur (C) and single transverse crease (D) suggest congenital abnormalities.