Nokea
The nurse is talking with a group of parents about puberty. The nurse should include that the first sign of puberty in clients of the male sex is
- A. increased height
- B. greater muscle mass
- C. testicular enlargement
- D. increased length of the penis
Correct Answer: C
Rationale: Testicular enlargement (C) is the first sign of puberty in males, occurring before height increase (A), muscle mass gain (B), or penile growth (D).
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While assisting a doctor with a sterile dressing change, the nurse notices that the doctor has contaminated his left hand. Which action should the nurse take?
- A. Hand the doctor another pair of gloves.
- B. Tell the doctor that he has contaminated his gloves.
- C. Say nothing because the client will be placed on prophylactic antibiotics.
- D. Report the incident to the infection control nurse.
Correct Answer: B
Rationale: Telling the doctor about the contamination maintains sterility and patient safety. Handing gloves assumes he noticed. Antibiotics are not a substitute for sterility. Reporting is secondary to immediate action.
The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter?
- A. Ensure the client understands the procedure prior to implementation
- B. Maintain a sterile field and keep the urinary catheter sterile
- C. Place the catheter supply kit between the client's legs in the center of the bed
- D. Throw swabs used to clean the perineum directly into the biohazard bin
Correct Answer: B
Rationale: Maintaining a sterile field (B) is critical to prevent infection, especially in a disoriented client. Explaining the procedure (A) is ideal but not feasible, kit placement (C) is secondary, and swab disposal (D) follows insertion.
When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?
- A. Speak directly to the interpreter while presenting information and use pauses for questions
- B. Talk to the interpreter in advance and leave the client and interpreter alone
- C. Include a family member and direct communications to that person
- D. Face the client while presenting the information as the interpreter talks in the native language
Correct Answer: D
Rationale: Face the client while presenting the information as the interpreter talks in the native language. This allows non-verbal communication and maintains a client-focused approach.
The family of a 90-year-old resident in a long-term care facility asks the nurse why the client only gets a shower three times a week. What information is most important for the nurse to include when answering the question?
- A. The staff members have limited time and must schedule all the residents.
- B. The client's skin is dry; too many showers will dry the skin further.
- C. The client has limited energy and must conserve it.
- D. The client is not very active and doesn't get very dirty.
Correct Answer: B
Rationale: Frequent showers can exacerbate dry skin in elderly clients, increasing irritation or breakdown risk. Staffing, energy, or activity levels are less relevant to skin health.
An adult is scheduled for a paracentesis. What should the nurse plan to do immediately before the procedure is started?
- A. Give the client a full glass of water
- B. Have the client empty his/her bladder
- C. Ask the client to empty his/her bowels
- D. Administer diazepam (Valium) as ordered
Correct Answer: B
Rationale: Emptying the bladder before paracentesis prevents accidental puncture of the bladder during needle insertion into the abdominal cavity. Water intake, bowel emptying, or sedation are not immediate pre-procedure priorities.