Nokea
The nurse is preparing to obtain a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter that was inserted 2 days ago. Which of the following actions should the nurse take?
- A. Attach a sterile syringe to the specimen port.
- B. Withdraw a sample of fluid from the balloon port.
- C. Empty urine from the urinary drainage bag into a specimen container.
- D. Collect all urine from the urinary drainage bag during a 24-hour period.
Correct Answer: A
Rationale: Using a sterile syringe at the specimen port (A) ensures a clean sample. Balloon port (B), drainage bag (C), or 24-hour collection (D) risk contamination.
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A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which of the following interventions does the nurse anticipate to prevent wound dehiscence? Select all that apply.
- A. Administer docusate sodium orally every day
- B. Assist in applying an abdominal binder
- C. Implement caloric restriction to promote weight loss
- D. Monitor blood glucose to maintain tight control
- E. Reinforce teaching to hug a pillow while coughing
Correct Answer: B, D, E
Rationale: Abdominal binder (B), glucose control (D), and pillow hugging (E) reduce wound stress and promote healing. Docusate (A) prevents constipation but not dehiscence, and caloric restriction (C) is inappropriate post-surgery.
A new client is admitted with a major abscess on her thigh caused by scratching mosquito bites with dirty hands after digging in her garden. She is on isolation precautions in a private room after surgical debridement. The physician changes her dressings daily. What should the nurse wear when providing care for this client?
- A. An N95 respirator and gloves
- B. Eye protection and a face mask
- C. Gloves and gown
- D. A gown only
Correct Answer: C
Rationale: Gloves and gown are required for contact precautions due to the abscess, preventing transmission of infection.
A client who received complete thickness burns at 7:30 a.m. was rushed to the emergency room where IV therapy with Lactated Ringer's was begun. He is to receive $8,000 \mathrm{~mL}$ of solution in 24 hours. According to the Parkland formula, how much solution should he receive by 11:30 p.m.?
- A. 4,000 mL
- B. 5,000 mL
- C. 6,000 mL
- D. 7,000 mL
Correct Answer: C
Rationale: The Parkland formula states half the total fluid (4,000 mL) is given in the first 8 hours (by 3:30 p.m.), and the remaining 4,000 mL over the next 16 hours. By 11:30 p.m. (16 hours post-burn), the client should have received 6,000 mL.
The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate?
- A. Assisting the parents in signing Against Medical Advice (AMA) papers
- B. Discharging the child if parents have power of attorney papers
- C. Notifying the hospital administration about the situation
- D. Reassuring the parents that their decision will be respected under the principle of autonomy
Correct Answer: C
Rationale: A 4-year-old with suspected meningitis requires urgent treatment. Notifying administration (C) ensures legal and ethical intervention to protect the child. AMA (A), power of attorney (B), or respecting autonomy (D) are inappropriate for a minor.
The nurse performs an assessment during a fluid exchange for the client who is 48 hours post-insertion of an abdominal Tenckhoff catheter for peritoneal dialysis. The nurse knows that the appearance of which of the following needs to be reported to the provider immediately?
- A. slight pink-tinged drainage
- B. abdominal discomfort
- C. muscle weakness
- D. cloudy drainage
Correct Answer: D
Rationale: Cloudy drainage is a sign of infection that can lead to peritonitis (inflammation of the peritoneum). The other options are expected side effects of peritoneal dialysis.