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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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A client with diabetes phones the clinic stating, 'I have a terrible cold and I don't know what to do about taking my insulin.' Which of the following should be included in the nurse's teaching regarding the client's insulin needs?
- A. Infections decrease insulin needs, so she should withhold insulin injections until her cold symptoms improve.
- B. Infections cause a drop in blood glucose levels, so she should base her insulin needs on the results of urine glucose tests.
- C. Infections cause alterations and increase insulin needs, so she should check her blood glucose levels and urine ketones at least every 4 hours.
- D. Infections cause no change in insulin requirements, but she should avoid crowds and overfatigue.
Correct Answer: C
Rationale: Infections increase insulin resistance, raising insulin needs. Frequent glucose and ketone monitoring ensures proper management. Withholding insulin or relying on urine tests is dangerous, and infections do alter insulin requirements.
The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply.
- A. Area around the insertion site feels cool to the touch
- B. Client reports mild arm discomfort after the infusion is started
- C. Edema is observed on the dependent side of the involved arm
- D. Intraoperative peripheral IV catheter was placed in the left antecubital region
- E. Serous fluid is leaking from the site despite secure connections
Correct Answer: A,C,E
Rationale: Coolness suggests infiltration or poor circulation. Edema indicates infiltration or phlebitis. Leaking serous fluid suggests dislodgement. Mild discomfort may be normal initially, and antecubital placement is acceptable unless complications arise.
The nurse is talking with a client who has Huntington disease and is considering becoming pregnant. Which of the following statements would be appropriate for the nurse to make?
- A. There are alternative methods to expand your family. You should consider adoption.
- B. Genetic counseling is recommended. You will receive a referral before you leave.
- C. Huntington disease inheritance requires both biological parents to carry the gene.
- D. Huntington disease occurs spontaneously and is not likely to affect your children.
Correct Answer: B
Rationale: Huntington's is autosomal dominant, so genetic counseling is essential. Adoption dismisses the client's wishes, both parents carrying the gene is incorrect, and spontaneous occurrence is false.
The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do?
- A. Bend at the waist
- B. Keep the feet close together
- C. Pivot on the foot proximal to the chair
- D. Use a transfer belt
Correct Answer: D
Rationale: A transfer belt ensures safety during transfers. Bending at the waist , close feet , and pivoting increase fall risk.
The nurse is reinforcing teaching about newly prescribed clonidine for a client with hypertension. Which of the following information would be most important for the nurse to reinforce?
- A. Avoid consuming high-sodium foods
- B. Do not stop taking the medication abruptly
- C. Limit alcohol intake while taking the medication
- D. Use an oral moisturizer to relieve dry mouth
Correct Answer: B
Rationale: Abruptly stopping clonidine can cause rebound hypertension, a critical risk. Sodium , alcohol , and dry mouth are less urgent.