Nokea
The nurse is inserting an indwelling urinary catheter in a male client. It would be appropriate for the nurse to inflate the catheter's balloon when
- A. Meeting resistance.
- B. As soon as urine is observed in the tubing.
- C. After advancing to the point of bifurcation.
- D. After fully advancing the length of the catheter.
Correct Answer: C
Rationale: The balloon should be inflated after advancing the catheter to the bifurcation (Y-connector), ensuring it is in the bladder. Inflating too early or fully advancing risks trauma or improper placement.
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While scheduling a client for thoracentesis, the nurse understands which of the following is the most preferred position for the procedimiento?
- A. Sitting up, leaning over a bedside table, and feet supported on the ground or stool.
- B. The head of the bed flat with the patient lying on the unaffected side.
- C. Prone position with both arms extended above the head.
- D. The head of the bed elevated 45 degrees, and the patient lying on the affected side.
Correct Answer: A
Rationale: Sitting up and leaning forward maximizes lung expansion and pleural fluid access for thoracentesis. Other positions restrict access or increase complication risk.
The nurse cares for a client with a double-lumen peripherally inserted central catheter (PICC). Which of the following actions would be appropriate for the nurse to take?
- A. Assign the client to a private room.
- B. Change the dressing daily using sterile technique.
- C. Flush heparin prior to discontinuation.
- D. Aspirate each lumen for blood return and then flush.
Correct Answer: D
Rationale: Aspirating for blood return and flushing ensures PICC patency. Private rooms, daily dressing changes, and heparin flushing are not standard unless specified.
The nurse is caring for a child immediately postoperative following a left ear myringotomy. The nurse should position the child
- A. left lateral recumbent
- B. prone
- C. right lateral recumbent
- D. modified trendelenburg
Correct Answer: C
Rationale: Positioning the child on the right lateral recumbent side (operative ear up) post-myringotomy facilitates drainage from the left ear and prevents pressure on the surgical site. Left lateral recumbent or prone positions could obstruct drainage, and modified Trendelenburg is not indicated.
The nurse is caring for a client with human immunodeficiency virus (HIV). It would be appropriate for the nurse to assign the client to a room with the client diagnosed with
- A. Infectious mononucleosis.
- B. Mycoplasma pneumonia.
- C. Gastroenteritis (rotavirus).
- D. Mumps (infectious parotitis).
Correct Answer: A
Rationale: HIV is not airborne or droplet-transmitted, so rooming with a client with mononucleosis (non-respiratory transmission) is safe. Mycoplasma, rotavirus, and mumps require specific precautions.
The nurse is planning a staff development conference about ways to prevent the transmission of the hepatitis C virus to healthcare workers. It would be appropriate for the nurse to cover which topic?
- A. How to obtain the HCV vaccine
- B. How to dispose of sharps safely
- C. How to dispose of urine and feces for those with HCV
- D. Isolation precautions for individuals with HCV
Correct Answer: B
Rationale: Safe sharps disposal prevents needlestick injuries, a primary transmission route for HCV. No vaccine exists, and urine/feces disposal or isolation are less relevant.