Nokea
The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide?
- A. Stroke the inner thigh below the perineum to initiate urinary flow
- B. Contract, hold, and then relax the pubococcygeal muscle
- C. Pour warm water over the external sphincter at the distal glans
- D. Apply downward manual pressure at the suprapubic regions
Correct Answer: D
Rationale: The client is applying pressure in the wrong region (umbilical area) and should be instructed to apply pressure at the suprapubic area. Applying downward manual pressure at the suprapubic region helps in emptying the bladder effectively by assisting in pushing the urine out through the urethra. Choices A, B, and C are incorrect because they do not address the specific issue of applying pressure to help empty the bladder using the Crede Method.
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A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client?
- A. Come to the clinic to be seen by a healthcare provider
- B. Increase your fluid intake and rest at home
- C. Take over-the-counter antiemetics as needed
- D. Monitor your symptoms and call if they worsen
Correct Answer: A
Rationale: The correct answer is to advise the client to come to the clinic to be seen by a healthcare provider. Persistent vomiting during pregnancy can lead to dehydration, which requires medical evaluation. Choice B is incorrect because solely increasing fluid intake and resting at home may not be sufficient to address the potential dehydration and underlying causes of vomiting. Choice C is not recommended without medical evaluation, as over-the-counter antiemetics should be used under healthcare provider guidance during pregnancy. Choice D is not the best option here because with persistent vomiting and risk of dehydration, immediate medical assessment is crucial to ensure the well-being of both the client and the fetus.
A client with a history of chronic heart failure is admitted with shortness of breath. Which assessment finding is most concerning?
- A. Crackles in the lungs
- B. Shortness of breath
- C. Elevated liver enzymes
- D. Heart rate of 100 beats per minute
Correct Answer: C
Rationale: Elevated liver enzymes are concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. While crackles in the lungs and shortness of breath are common in heart failure, elevated liver enzymes specifically point towards possible liver involvement due to heart failure. A heart rate of 100 beats per minute can be expected in a client with heart failure due to compensatory mechanisms, but elevated liver enzymes signal a more severe condition.
What is the most important instruction for the nurse to provide a client being discharged following treatment for Guillain-Barre syndrome?
- A. Avoid exposure to respiratory infections.
- B. Use relaxation exercises when anxious.
- C. Continue physical therapy at home.
- D. Plan short, frequent rest periods.
Correct Answer: A
Rationale: The most critical instruction for a client being discharged following treatment for Guillain-Barre syndrome is to avoid exposure to respiratory infections. Guillain-Barre syndrome can affect the respiratory system, making infections particularly dangerous. While relaxation exercises, physical therapy, and rest periods are beneficial for overall well-being and recovery, preventing respiratory infections takes precedence due to the potential life-threatening complications associated with respiratory compromise in Guillain-Barre syndrome.
In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60 mm Hg, a pulse rate of 118 beats per minute, and a respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?
- A. Note the appearance and patency of the client's peripheral IV site.
- B. Palpate the volume of the client's right radial pulse.
- C. Auscultate the client's breath sounds bilaterally.
- D. Observe the amount and dose of morphine in the PCA pump syringe.
Correct Answer: D
Rationale: In this scenario, the client is presenting with signs of potential opioid overdose, such as lethargy, hypotension, tachycardia, and bradypnea. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This evaluation is crucial in determining if the client is receiving an excessive amount of morphine, leading to the observed symptoms. Checking the PCA pump syringe will provide essential information to address the client's condition promptly and prevent further complications. Choices A, B, and C are not the priority in this situation as they do not directly address the potential cause of the client's symptoms related to morphine administration.
Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated, and his blood pressure drops to 60/40. Which intervention should the nurse implement?
- A. Administer a second dose of nitroglycerin.
- B. Infuse a rapid IV normal saline bolus.
- C. Begin external chest compressions.
- D. Give a PRN antiemetic medication.
Correct Answer: B
Rationale: In this scenario, the client's symptoms of nausea and a significant drop in blood pressure suggest a potential right ventricular infarction. The appropriate intervention for this situation is to infuse a rapid IV normal saline bolus. This fluid resuscitation helps improve cardiac output by increasing preload, which can be beneficial in right ventricular infarction. Administering a second dose of nitroglycerin may further lower blood pressure. External chest compressions are not indicated in this case as the client has a pulse. Providing an antiemetic medication does not address the underlying issue of hypotension and potential right ventricular involvement.