Nokea
The nurse is observing the UAP providing direct care to a client with an indwelling catheter. Which data warrant immediate intervention by the nurse?
- A. The UAP secures the tubing to the client’s leg with tape.
- B. The UAP provides catheter care with the client’s bath.
- C. The UAP puts the collection bag on the client’s bed.
- D. The UAP cares for the catheter after washing the hands.
Correct Answer: C
Rationale: Placing the collection bag on the bed risks contamination and infection, as it should be below bladder level and off surfaces. Securing tubing, providing care during bathing, and hand washing are appropriate.
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The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply.
- A. Place the solution on an IV pump at the prescribed rate.
- B. Monitor blood glucose every six (6) hours.
- C. Weigh the client weekly, first thing in the morning.
- D. Change the IV tubing every three (3) days.
- E. Monitor intake and output every shift.
Correct Answer: A,B,E
Rationale: TPN requires an IV pump for precise delivery, frequent glucose monitoring due to high dextrose content, and intake/output monitoring to assess fluid balance. Weekly weights and tubing changes every 3 days are less critical or incorrect.
Which nursing intervention is most appropriate when the nurse is changing the appliance of the client's ileal conduit?
- A. When you remove the appliance, let the urine drip into a container.
- B. When you remove the appliance, insert a tampon into the stoma.
- C. When you remove the appliance, press a gloved finger over the stoma.
- D. When you remove the appliance, pinch the stoma with two fingers.
Correct Answer: C
Rationale: Pressing a gloved finger over the stoma prevents urine leakage during appliance changes, maintaining hygiene and skin integrity.
The client from a long-term care facility is admitted to the medical unit with a fever, hot flushed skin, and clumps of white sediment in the indwelling catheter. Which intervention should the nurse implement first?
- A. Start an IV with a 20-gauge catheter.
- B. Initiate antibiotic therapy IVPB.
- C. Collect a urine specimen for culture.
- D. Change the indwelling catheter.
Correct Answer: C
Rationale: Symptoms suggest a catheter-associated UTI. Collecting a urine culture first identifies the causative organism, guiding antibiotic therapy. Starting an IV, antibiotics, or changing the catheter are secondary to obtaining a diagnostic sample.
The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition is a cause for these findings?
- A. Overhydration.
- B. Anemia.
- C. Dehydration.
- D. Renal failure.
Correct Answer: C
Rationale: Elevated hematocrit (56%) and hypernatremia (152 mEq/L) indicate dehydration, which concentrates blood components and sodium. Overhydration dilutes these values, anemia lowers hematocrit, and renal failure typically causes hyponatremia.
When administering the bladder instillation containing the chemotherapeutic drug, which safety precaution is most important for the nurse to take?
- A. Wear two pairs of latex gloves.
- B. As a mass syringe for the drug.
- C. Avoid wearing clothing with long sleeves.
- D. Limit contact time with the client.
Correct Answer: A
Rationale: Wearing two pairs of latex gloves protects the nurse from exposure to the chemotherapeutic drug during instillation.