Nokea
The nurse is talking with a female client about collecting a clean-catch urine specimen. Which of the following information should the nurse include? Select all that apply.
- A. Avoid touching the inside of the specimen container.
- B. Position the specimen container before initiating your stream of urine.
- C. Cleanse your vulva from front to back with single-use antiseptic towelettes.
- D. Spread your labia using your nondominant hand before cleansing your perineum and urinating.
- E. Remove the lid from the specimen container and place it on the counter with the sterile side facing down.
Correct Answer: A,C,D
Rationale: Avoiding contamination, proper cleansing, and spreading the labia are critical for a clean-catch specimen. The lid should be placed sterile side up, and the container should be positioned midstream.
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Triazolam (Halcion) 0.25 mg is ordered for a client at bedtime. When the nurse goes to give the medication, the client asks the nurse to leave it at the bedside because she wants to finish reading a book. What is the best action for the nurse to take?
- A. Leave the medication at the bedside as requested
- B. Return in one hour and offer the medication again
- C. Tell the client to call when she is ready for the medication
- D. Explain to the client that this is the time medications are given and she should take it now
Correct Answer: B
Rationale: Returning in an hour ensures medication administration while respecting the client's request, adhering to safety protocols. Leaving medication or delaying indefinitely risks errors.
In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in
- A. Hearing, speech, and sight
- B. Endurance, strength, and mobility
- C. Learning, creativity, and judgment
- D. Balance, flexibility, and coordination
Correct Answer: C
Rationale: Learning, creativity, and judgment. Cognitive impairments are due to physiological processes that affect memory and other higher-level cognitive processes.
A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include?
- A. Allow the child to continue normal activities
- B. Schedule frequent rest periods
- C. Limit exposure to other children
- D. Restrict activities to inside the house
Correct Answer: A
Rationale: Allow the child to continue normal activities. Physical activity supports autonomy and mucus secretion in cystic fibrosis.
An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, 'Where do babies come from?' What is the nurse's best response to the parent?
- A. When a child asks a question, give a simple answer.
- B. Children ask many questions, but are not looking for answers.
- C. This question indicates interest in sexual development.
- D. Full and detailed answers should be given to all questions.
Correct Answer: A
Rationale: When a child asks a question, give a simple answer. Honesty is important, but answers should be simple and age-appropriate, providing only the information the child is ready to understand.
A client is scheduled for an elective laparoscopic prostatectomy in the morning. The practical nurse should notify the registered nurse about which of the following assessment data as soon as possible before surgery?
- A. INR level
- B. platelet count
- C. hemoglobin and hematocrit levels
- D. temperature 100.4 F (38 C) with cough
Correct Answer: D
Rationale: A temperature of 100.4 F with cough suggests a possible infection, which could contraindicate surgery due to increased risk of complications.