Nokea
The nurse is reinforcing teaching for a client with suspected Cushing syndrome who has a 24-hour urine specimen. Which of the following information should the nurse reinforce? Select all that apply.
- A. An indwelling urinary catheter will be inserted for this test and your urine will be collected in an attached drainage bag.
- B. Discard your first void in the toilet and then record the start time of the urine collection so that the start time coincides with an empty bladder.
- C. Keep the collection container in the refrigerator or a cooled ice chest when it is not in use.
- D. Only daytime urine should be collected in the container because cortisol levels are higher in the morning.
- E. You will be given an opaque plastic container to collect your urine to protect it from light.
Correct Answer: B,C
Rationale: Discarding the first void and recording the start time (B) ensures accurate collection, and refrigerating the container (C) preserves the sample. Catheters (A) are not needed, all urine is collected (D is incorrect), and light protection (E) is unnecessary.
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A charge nurse working in a long term care facility is making out assignments. Which assignment made by a registered nurse to an unlicensed assistive personnel (UAP) requires intervention by the supervisor?
- A. Provide decubitus ulcer care and apply a dry dressing
- B. Bathe and feed a client on bed rest
- C. Oral suctioning of an unresponsive elderly client
- D. Teaching a family intermittent (bolus) feedings via G-tube before discharge
Correct Answer: D
Rationale: Teaching a family intermittent (bolus) feedings via G-tube before discharge. Initial teaching cannot be delegated to a UAP or a PN and must be done by RNs.
The nurse is talking with the parent of an adolescent client who has infectious mononucleosis. Which of the following statements by the parent would require follow-up?
- A. My child may take acetaminophen for fever or discomfort.
- B. My child will need to complete a full course of antibiotic therapy.
- C. My child should avoid participating in contact sports for at least 3 weeks.
- D. My child may continue to experience fatigue after the fever and sore throat subside.
Correct Answer: B
Rationale: Mononucleosis is viral, so antibiotics (B) are not indicated, requiring follow-up. Acetaminophen (A), avoiding sports (C), and prolonged fatigue (D) are correct.
A client with a history of degenerative arthritis is being discharged home following exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should reinforce which of the following topics with the client? Select all that apply.
- A. Dryness of the mouth and throat may occur
- B. Ringing in the ears is an expected, transient side effect
- C. The albuterol canister should not be shaken before use
- D. The health care provider should be notified if stools are black and tarry
- E. Tiotropium capsules should not be swallowed
Correct Answer: A,D,E
Rationale: Dry mouth (A) is a side effect of COPD medications, black stools (D) may indicate GI bleeding, and tiotropium capsules are inhaled, not swallowed (E). Ringing in ears (B) is not expected, and albuterol should be shaken (C).
A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?
- A. dyspnea
- B. heart murmur
- C. macular rash
- D. Hemorrhage
Correct Answer: B
Rationale: Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli.
The nurse has attended a staff education program about administering intramuscular injections. Which of the following statements by the nurse would indicate a correct understanding of the program?
- A. I will insert the needle at a 45-degree angle.
- B. I will wait 3 seconds after injecting the medication before removing the needle.
- C. I will gently massage the injection site after removing the needle.
- D. I will use my hand to displace subcutaneous tissue prior to inserting the needle.
Correct Answer: D
Rationale: Displacing subcutaneous tissue (D) via the Z-track method prevents leakage and irritation. IM injections use a 90-degree angle (A is incorrect), waiting 3 seconds (B) is not standard, and massaging (C) is avoided for some medications.