Nokea
The nurse is inserting an indwelling urinary catheter in an adult woman. The nurse locates landmarks before inserting the catheter. The urethral opening is located:
- A. above the clitoris.
- B. behind the vagina.
- C. between the clitoris and the vagina.
- D. between the vagina and the rectum.
Correct Answer: C
Rationale: The female urethral opening is located between the clitoris and vagina, a key landmark for catheter insertion to avoid incorrect placement.
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A client is admitted to the hospital with findings of liver failure with ascites. The health care provider orders spironolactone (Aldactone). What is the pharmacological effect of this medication?
- A. Promotes sodium and chloride excretion
- B. Increases aldosterone levels
- C. Depletes potassium reserves
- D. Combines safely with antihypertensives
Correct Answer: A
Rationale: Spironolactone promotes sodium and chloride excretion while sparing potassium and decreasing aldosterone levels. It has no effect on ammonia levels.
A client with pernicious anemia is admitted. What would the nurse expect the admitting assessment to reveal?
- A. Ecchymoses on the trunk
- B. Bilateral neuropathy of the legs
- C. Decreased platelet count
- D. Decreased appetite
Correct Answer: B
Rationale: Pernicious anemia, a vitamin B12 deficiency, often causes neurological symptoms like bilateral leg neuropathy due to nerve demyelination.
Following surgery for placement of a ventriculoperitoneal (VP) shunt as treatment for hydrocephalus, the parents question why the infant has a small abdominal incision. The best response by the nurse would be to explain that the incision was made in order to
- A. Pass the catheter into the abdominal cavity
- B. Place the tubing into the urinary bladder
- C. Visualize abdominal organs for catheter placement
- D. Insert the catheter into the stomach
Correct Answer: A
Rationale: Pass the catheter into the abdominal cavity. The VP shunt drains cerebrospinal fluid into the peritoneal cavity via a catheter inserted through an abdominal incision.
An infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis.
Which of the following should be the nursing priority for an infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis?
- A. Encourage intake of oral fluids to prevent dehydration.
- B. Restrain the child appropriately to maintain the integrity of the IV site.
- C. Place the child on droplet precautions.
- D. Encourage the parents to hold and rock the infant to promote comfort.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) fluid requirements are determined by child's hydration status; fluids are usually limited to prevent cerebral edema (2) not a priority (3) correct-to prevent spread of infection, child is placed on droplet precautions for at least 24 hours after implementation of antibiotic therapy (4) would cause discomfort to infant's head
The nurse is caring for a client with a history of chronic kidney disease.
- A. Which dietary restriction is most important for a client with chronic kidney disease?
- B. Low-sodium diet.
- C. Low-carbohydrate diet.
- D. High-protein diet.
- E. High-fat diet.
Correct Answer: A
Rationale: A low-sodium diet reduces fluid retention and hypertension in chronic kidney disease. Protein is restricted, carbohydrates are encouraged, and high-fat diets are not indicated.