Nokea
The nurse is preparing to obtain a urine specimen for urinalysis from an 18-month-old client. Which of the following actions should the nurse take?
- A. Perform intermittent straight catheterization to obtain the urine from the client.
- B. Apply an adhesive urine collection bag around the client's genital area.
- C. Ask the parent to obtain the client's urine using a specimen cup
- D. Place a urine dipstick in the client's diaper overnight.
Correct Answer: B
Rationale: An adhesive collection bag is non-invasive and effective for toddlers. Catheterization is invasive, a cup is impractical, and a dipstick is inaccurate.
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The nurse is caring for a client who is experiencing the cardiac rhythm shown in the ECG strip below. The nurse should recognize that the client is experiencing
- A. atrial fibrillation
- B. ventricular fibrillation
- C. sinus bradycardia
- D. normal sinus rhythm
Correct Answer: B
Rationale: Ventricular fibrillation is a life-threatening arrhythmia requiring immediate intervention. Atrial fibrillation , sinus bradycardia , and normal rhythm are less urgent.
A client who is scheduled for surgery today says to the nurse, 'Do you think I'll survive the surgery?' What is the best initial response for the nurse to give?
- A. Don't worry, your surgeon is good.'
- B. Tell me about your concerns.'
- C. I can call your clergyman.'
- D. We do a lot of these surgeries here; everything will be okay.'
Correct Answer: B
Rationale: Exploring concerns validates the client's fears, fostering trust and addressing anxiety therapeutically.
The nurse is talking with a client with major depressive disorder who is receiving isocarboxazid. Which of the following statements by the client would be a priority to follow up?
- A. I am feeling fatigued at the end of most days.
- B. I have been experiencing constipation recently
- C. I have been gaining weight since I started taking the medication
Correct Answer: A
Rationale: Fatigue may indicate worsening depression or MAOI side effects, requiring urgent follow-up. Constipation and weight gain are common but less critical.
The nurse is reinforcing teaching of proper technique for colostomy irrigation for the home health client. Which client action indicates that further instruction is required?
- A. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place
- B. Fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing
- C. Hangs the irrigation container on a hook at the level of the shoulder approximately 18-24 inches above the stoma
- D. Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs
Correct Answer: A
Rationale: Using an enema set is incorrect; a cone-tipped irrigator is required for safe colostomy irrigation. Water volume , height , and clamping are correct.
The nurse is discussing iron deficiency anemia with a community group. Which of the following persons are at risk for iron deficiency anemia? Select all that apply.
- A. A 15-month-old who drinks a lot of milk
- B. A 6-year-old who has sickle cell anemia
- C. An adolescent female
- D. A woman who is 8 months pregnant
- E. An African-American middle-aged man
- F. A 78-year-old on a fixed income
Correct Answer: A,C,D,F
Rationale: Toddlers drinking excessive milk, adolescent females (due to menstruation), pregnant women (increased iron demand), and elderly on fixed incomes (poor diet) are at risk. Sickle cell anemia and African-American males are not specific risk factors.