Nokea
The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?
- A. Power flush with 60 mL to remove mucous obstructions.
- B. Slowly irrigate catheter with saline using an infusion pump.
- C. Clamp the catheter for 30 minutes prior to irrigating.
- D. Use a sterile syringe to irrigate with 20 mL normal saline.
Correct Answer: B
Rationale: Slow irrigation safely clears clots and sediment.
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The nurse observes a colleague sharing computer credentials with a colleague who is struggling with access to the electronic health record (EHR). Which action should the nurse take?
- A. Warn the colleague that their actions are unprofessional.
- B. Discuss the action at the next staff meeting.
- C. Communicate the observation to the charge nurse.
- D. File a detailed incident report with the specific facility.
Correct Answer: C
Rationale: Reporting to the charge nurse ensures prompt action.
The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?
- A. Position the client in a lateral lying position.
- B. Document the blood pressure and monitor the client.
- C. Encourage an increase in oral fluid intake.
- D. Hold the medication and notify the healthcare provider.
Correct Answer: D
Rationale: Holding medication prevents worsening hypotension.
The nurse receives a new prescription to administer oxygen at 3 L/minute via a nasal cannula to maintain an oxygen saturation between 90 and 100% for an adult client. The nurse obtains an oxygen saturation reading of 85% and, after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?
- A. Place the client in a Trendelenburg position.
- B. Document the second reading in the client record.
- C. Securely place the prongs of the cannula in the nostrils.
- D. Place the pulse oximeter on the client's earlobe.
Correct Answer: C
Rationale: Proper cannula placement ensures effective oxygen delivery.
The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?
- A. Review the intake and output record.
- B. Give the client 8 ounces of water to drink.
- C. Notify the healthcare provider.
- D. Check the drainage tubing for a kink.
Correct Answer: D
Rationale: Checking for kinks ensures catheter functionality.
During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Send a list of medication allergies to the pharmacy.
- B. Secure an allergy bracelet around the client's wrist.
- C. Notify the dietary department of the client's fruit allergy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: B
Rationale: Allergy bracelet ensures immediate awareness.