Nokea
The nurse is precepting a student nurse on an orthopedic floor. The student nurse needs to insert an indwelling catheter into a male client. Which of the following statements by the student nurse are correct regarding insertion of the catheter? Select all that apply.
- A. I need to establish an aseptic field.
- B. I will place the client in the supine position.
- C. I will lubricate the tip of the catheter with sterile lubricant included in the tray.
- D. I will inflate the catheter balloon with 5 cc of sterile water.
Correct Answer: A,B,C
Rationale: Aseptic technique, supine positioning, and sterile lubrication are correct for catheter insertion. Inflating the balloon with 5 cc is incorrect, as most catheters require 10 cc of sterile water for balloon inflation.
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A client who has undergone a thyroidectomy complains of numbness, tingling, and stiffness in her hands, feet, and face as well as muscle tremors, spasmodic muscle contractions, and anxiety during the postoperative period. Which laboratory tests does the nurse anticipate that the physician will request?
- A. Hemoglobin.
- B. Sodium.
- C. Thyroid-stimulating hormone (TSH).
- D. Calcium.
Correct Answer: D
Rationale: Numbness, tingling, and muscle spasms post-thyroidectomy suggest hypocalcemia due to parathyroid gland disruption. The physician will likely request a calcium level test (D). Hemoglobin (A), sodium (B), and TSH (C) are not directly related to these symptoms.
The nurse recognizes that if eaten by a client, which food can alter results when stool is checked for occult blood?
- A. potatoes
- B. dairy products
- C. raw fruits
- D. beef
Correct Answer: D
Rationale: Beef contains heme, which can cause a false-positive result in a fecal occult blood test. Other foods listed do not typically interfere.
A client with rheumatoid arthritis tells the nurse that she is having increasing difficulty cooking, cleaning, and attending to activities of daily living. Which of the following referrals is the most appropriate?
- A. Occupational therapist.
- B. Physical therapist.
- C. Home health agency.
- D. Assisted-living facility.
Correct Answer: A
Rationale: An occupational therapist (A) helps clients with rheumatoid arthritis adapt to difficulties with daily activities through adaptive techniques and equipment. Physical therapy (B), home health (C), or assisted living (D) may be secondary.
The nurse recognizes all of the following as type IV hypersensitivity reactions EXCEPT
- A. allergic contact dermatitis.
- B. Crohn's disease.
- C. graft versus host disease.
- D. penicillin allergy.
Correct Answer: D
Rationale: Type IV hypersensitivity is cell-mediated (e.g., contact dermatitis, Crohn’s, GVHD). Penicillin allergy is typically type I (IgE-mediated).
A client diagnosed with hemophagocytic lymphohistiocytosis requires multiple blood transfusions. One of his family members wishes to donate blood. Which of the following conditions would DISQUALIFY someone from donating blood?
- A. current medical condition of hyperthyroidism
- B. new mother, 10 weeks postpartum
- C. currently ill with common cold
- D. past medical history of tuberculosis; completed treatment and recovered 3 years ago
Correct Answer: C
Rationale: Current illness (e.g., cold) disqualifies blood donation due to infection risk. Hyperthyroidism, postpartum (after 6 months), and treated TB (if fully recovered) may not disqualify.