Nokea
The nurse is planning a staff educational conference about indwelling urinary catheters. Which of the following information should the nurse include?
- A. Sterile gloves should be used to perform urinary catheter care.
- B. Urinary specimens may be collected from a catheter bag.
- C. You may irrigate a catheter with warm water for poor outflow.
- D. Daily use of soap and water should be used around the urinary meatus.
Correct Answer: D
Rationale: Daily soap and water cleaning around the urinary meatus prevents infection. Sterile gloves are not required, specimens from catheter bags are unreliable, and irrigation requires a prescription.
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The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 5 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Orders
• insert peripheral vascular access device
• serum type and screen
• transfuse two units of fresh frozen plasma
• perform a bedside swallow evaluation
• apply sequential compression devices
• obtain a complete metabolic panel (CMP)
The nurse has received orders from the physician. Select three (3) orders that the nurse should consider a priority.
- A. insert peripheral vascular access device
- B. serum type and screen
- C. transfuse two units of fresh frozen plasma
- D. perform a bedside swallow evaluation
- E. apply sequential compression devices
- F. obtain a complete metabolic panel
Correct Answer: A, B, C
Rationale: Peripheral access, serum type and screen, and FFP transfusion are priorities to manage bleeding risk from subarachnoid hemorrhage and elevated INR.
The nurse is caring for a client with suspected placenta previa. The nurse anticipates an order for which diagnostic test to confirm this finding?
- A. Manual cervical exam
- B. Transvaginal ultrasound
- C. Contraction stress test
- D. Nonstress test
Correct Answer: B
Rationale: Transvaginal ultrasound is the safest and most accurate method to confirm placenta previa, avoiding risky manual exams.
The nurse is caring for a client who is recovering from surgery. Which assessment data would suggest that the client's pain is not well controlled?
- A. Tachypnea
- B. Bradycardia
- C. Nausea
- D. Mydriasis
- E. Increased blood glucose
Correct Answer: A, C, E
Rationale: Tachypnea, nausea, and increased blood glucose are signs of uncontrolled pain.
The following scenario applies to the next 1 items
The nurse is caring for a 23-year-old male in the psychiatry clinic
Item 1 of 1
History and Physical
Chief Complaint – 23-year-old male presents with his mother, who insists, 'he needs some help; all he does is work and play video games and doesn't socialize with anyone.'
History of Present Illness – 23-year-old Caucasian male presents with his mother with reports of his asociality starting to impact his life. He reports that while in high school, he had a degree of anxiety about socializing with his peers. He thought that as the years passed, it would get better.
He states his anxiety has declined, but he gets paranoid around individuals because they may want to 'do him wrong.' He cannot point to an example of maleficence caused by his friends. He states he doesn't have a problem with his self-esteem, but sometimes social situations are avoided because 'I can see ahead into the future, and I want to avoid people who can bring me harm through their negative energy.' The client reports that he spends his time playing video games, stating he likes games that are fantasy related because 'they take me a while.' He states he has a strong interest in tarot card readings, and for his close friends, he does provide readings. He did offer the examiner a tarot card reading. His interest in tarot cards came from his self-described ability to interpret the spirits of individuals and their auras.
He states that occasionally, he will browse social media and identify a quote or lyric that he feels 'was directed towards me.' The client is employed as an overnight hotel clerk, and his highest level of education is a high school diploma. The client has never been married and has no children. His last relationship was seven years ago, which was brief. He identifies himself as heterosexual. He has a distant criminal history of petty theft and identity theft. No history of violent crimes. He has never been incarcerated. He denies drinking alcohol. However, he does smoke marijuana 2-3x a week. He lives in the basement with his Mother and declines to move out because he has no plans.
Medical History – No past medical history, no past psychiatric history. The client has never been hospitalized—no family history of psychiatric illness.
Mental Status Examination – Alert and fully oriented; Fair concentration; No psychomotor retardation or agitation; Cooperative behavior; Adequately groomed; unkept hair that is bright green in color. He has multiple facial piercings (nose, eyebrow, lip). Speech is at a normal rate with a slightly increased volume Affect is bright, and he describes his mood as 'okay.' Denies suicidal or homicidal ideations. Intact insight and judgment
Complete the sentence below by choosing from the list of options. The client is at highest risk of developing ___ as evidenced by the client's ___
- A. antisocial personality disorder
- B. bipolar disorder
- C. schizotypal personality disorder
- D. dependent personality disorder
- E. illogical thought content
- F. criminal history
- G. self-esteem
Correct Answer: C, E
Rationale: The client's paranoia, magical thinking (tarot cards, auras), and social avoidance suggest schizotypal personality disorder, evidenced by illogical thought content.
The nurse is caring for assigned clients and is reviewing laboratory data. Which laboratory data requires follow-up? A client with a
- A. serum total cholesterol 180 mg/dl (4.65 mmol/L)
- B. glycosylated hemoglobin (A1C) 7.5%
- C. serum calcium 9.2 mg/dl (2.30 mmol/L)
- D. serum creatinine 1.0 mg/dL (88.4 µmol/L)
Correct Answer: B
Rationale: An A1C of 7.5% is elevated for a client with diabetes mellitus (DM), as the target is typically ≤7%. This requires follow-up to assess glycemic control.