Nokea
The nurse is to insert an indwelling catheter in a male. Which action is appropriate?
- A. Cleanse the meatus before preparing the catheter for insertion
- B. Wash hands before starting the procedure
- C. Hold the penis at a 45-degree angle during insertion of the catheter
- D. Inflate the balloon immediately before inserting the catheter
Correct Answer: B
Rationale: Washing hands before catheter insertion is critical to maintain a sterile field and prevent infection. Cleansing the meatus occurs after hand washing, a 45-degree angle is incorrect (90 degrees is typical), and the balloon is inflated post-insertion.
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A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
- A. A cerebral vascular accident
- B. Postoperative meningitis
- C. Medication reaction
- D. Metabolic alkalosis
Correct Answer: A
Rationale: A cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, increasing the risk of thromboembolic events like cerebrovascular accidents, which can manifest as seizures.
The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?
- A. Daily needs and concerns
- B. The overview cardiac rehabilitation
- C. Medication and diet guideline
- D. Activity and rest guidelines
Correct Answer: A
Rationale: At 2 days post-MI, the client's education should be focused on the immediate needs and concerns for the day.
A client experiencing hallucinations.
Which of the following behaviors by a client should the nurse record to indicate that the client is experiencing hallucinations?
- A. The client sits immobilized for long periods of time.
- B. The client turns and tilts his head as if talking to someone.
- C. The client expresses the belief that the physician is out to get him.
- D. The client wrings his hands and paces constantly.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) describes behavior associated with depression (2) correct-hallucinations are sensory perceptions for which there is no external stimulus; this option describes client behavior that would be observed when the client is responding to voices (3) describes behavior associated with delusional thinking (4) describes behavior most associated with anxiety
A client admitted with a severe head injury following an MVA is placed on a ventilator, and hyperventilation is maintained. The primary reason for maintaining hyperventilation is:
- A. To increase oxygen to the brain
- B. To dilate the cerebral blood volume
- C. To increase the cerebral blood volume
- D. To promote cerebral vasoconstriction and decrease cerebral blood flow
Correct Answer: D
Rationale: Hyperventilation reduces $\mathrm{CO}_2$, causing cerebral vasoconstriction, which decreases cerebral blood flow and intracranial pressure in head injuries.
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
- A. Decreased urinary output
- B. Hypersomnolence
- C. Absence of knee jerk reflex
- D. Decreased respiratory rate
Correct Answer: B
Rationale: Hypersomnolence is an expected side effect of magnesium sulfate due to its sedative properties, so B is correct. Decreased urinary output , absence of knee jerk reflex , and decreased respiratory rate are signs of toxicity, not expected effects.