Nokea
The nurse is to remove an indwelling urinary catheter from an adult client. Which step should be done first?
- A. Cut the catheter with scissors.
- B. Withdraw the fluid from the balloon.
- C. Clamp the catheter.
- D. Remove the catheter.
Correct Answer: B
Rationale: Withdrawing fluid from the balloon deflates it, allowing safe catheter removal without urethral trauma. Cutting, clamping, or pulling without deflation risks injury.
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A client receiving cromolyn sodium (Intal).
Which of the following statements, if made by the client to the nurse, indicates that teaching has been successful?
- A. I will take the medicine with my meals.
- B. It is important that I take the medication before going to bed.
- C. If I experience respiratory distress, I will take the medicine.
- D. I will take the medicine before I begin any vigorous exercise.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate information (2) inappropriate information (3) cromolyn sodium is not an antihistamine agent, an antiinflammatory, or a bronchodilator, does nothing for a client in respiratory distress (4) correct-cromolyn sodium (Intal) is used to prevent the release of histamine and other allergy-triggering substances
A 23-year-old man comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back.
The nurse should instruct the client to
- A. clean the area carefully with soap and warm water every day and cover them with a sterile dressing.
- B. soak in a warm tub twice a day and rub the areas with a washcloth before covering them.
- C. shower daily using a mild antimicrobial soap from a pump dispenser and leave the lesions uncovered.
- D. clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine) and leave them open to the air.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered due to open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma
A patient several days after an above-knee amputation (AKA).
Which of the following symptoms would be characteristic of an infected stump wound?
- A. The patient is anxious and restless.
- B. There is a small amount of dark drainage on the dressing.
- C. The patient complains of persistent pain at the operative site.
- D. The skin is cool above the operative site.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to an infected wound. (1) may be due to changes in body image or pain (2) expected, not indicative of an infection (3) correct-pain is characteristic of inflammation and infection (4) warm skin above site would indicate infection
The LPN/LVN is caring for an adult who has pneumonia. The nurse should instruct the nursing assistant to report which information immediately?
- A. Restlessness
- B. Pink-colored skin
- C. Nonproductive cough
- D. Dry mouth
Correct Answer: A
Rationale: Restlessness may indicate hypoxia in pneumonia, a critical symptom requiring immediate reporting to assess oxygenation status.
A student nurse caring for a client while wearing a gown and gloves in addition to following standard precautions.
The nurse should determine that care is appropriate if the student nurse performs which of the following activities?
- A. Gives isoniazid (INH) to a client with tuberculosis.
- B. Administers an IM injection to a client with rubella.
- C. Delivers a food tray to a client with hepatitis.
- D. Changes the dressing for a client with a draining abscess.
Correct Answer: D
Rationale: Strategy: Determine how the organism of each disease is spread. (1) requires airborne precautions, particulate respirator (2) requires droplet precautions, nurse should wear a mask (3) requires standard precautions (4) correct-requires contact precautions