Nokea
The nurse is preparing to insert a urinary catheter. Which action ensures sterile technique?
- A. Cleanse the meatus with an alcohol swab
- B. Use clean gloves during insertion
- C. Apply sterile lubricant to the catheter tip
- D. Insert the catheter without a drape
Correct Answer: C
Rationale: Applying sterile lubricant to the catheter tip maintains sterile technique, reducing the risk of infection during urinary catheter insertion.
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Which of the following should the nurse identify as a priority nursing diagnosis for an infant with intussusception?
- A. Deficient fluid volume
- B. Impaired skin integrity
- C. Acute pain
- D. Impaired gas exchange
Correct Answer: C
Rationale: Acute pain is the priority nursing diagnosis for an infant with intussusception due to bowel obstruction causing severe abdominal pain. Fluid volume and gas exchange may be concerns but are secondary.
The nurse is teaching a client with hypertension about lifestyle modifications. Which of the following recommendations is most effective in reducing blood pressure?
- A. Increasing dietary potassium intake.
- B. Reducing daily sodium intake.
- C. Drinking one glass of red wine daily.
- D. Taking a daily multivitamin.
Correct Answer: B
Rationale: Reducing sodium intake is highly effective in lowering blood pressure by decreasing fluid retention and vascular resistance.
The nurse is caring for a client with a diagnosis of Parkinson's disease who is taking benztropine mesylate daily. When assessing the client, what should the nurse specifically monitor for to determine if the client is experiencing a side effect of this medication?
- A. Pupil response
- B. Prothrombin time
- C. Skin temperature
- D. Intake and output
Correct Answer: D
Rationale: Urinary retention is a side effect of benztropine mesylate, an anticholinergic medication. The nurse needs to observe for dysuria, distended abdomen, voiding in small amounts, and overflow incontinence. The remaining options do not relate to this medication.
The nurse instills 5 mL of normal saline before suctioning a client's tracheostomy tube. The instillation is effective when:
- A. The secretions are thinned.
- B. The client coughs.
- C. There is minimal friction when the catheter is passed into the tracheostomy tube.
- D. There is humidification for the respiratory tract.
Correct Answer: A
Rationale: Instilling normal saline thins secretions, facilitating effective suctioning of the tracheostomy tube.
The nurse is teaching a client with a new diagnosis of epilepsy about driving restrictions. Which of the following instructions is most appropriate?
- A. You can drive after being seizure-free for 6 months.
- B. You can drive if you take your medication regularly.
- C. You can drive with a passenger at all times.
- D. You can drive during the daytime only.
Correct Answer: A
Rationale: Most regions require a client to be seizure-free for 6 months before driving, ensuring safety.