Nokea
The nurse notes that sediment is present in the urine.
- A. Which of the following actions should the nurse take to obtain a sterile urine specimen?
- B. Disconnect the catheter from the collection tubing.
- C. Obtain the specimen from the retention port.
- D. Use the balloon port to obtain the sterile specimen.
- E. Unclamp the collection port below the bag
Correct Answer: B
Rationale: Retention ports allow sterile specimen collection.
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Select the 5 findings the nurse should plan to include in the report.
- A. Client's report of lack of food in home
- B. ECG results
- C. Numerous bruises in various stages of healing
- D. Client's avoidance of eye contact
- E. Client's report of lack of access to bank accounts
- F. Client’s report of weight loss
Correct Answer: A,C,D,E,F
Rationale: These findings highlight potential abuse and neglect indicators.
A nurse is assessing a client who is taking haloperidol and is experiencing pseudo parkinsonism. Which of the following findings should the nurse document as a manifestation of pseudo parkinsonism?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudo parkinsonism is a common side effect of antipsychotic medications like haloperidol. A shuffling gait is a characteristic manifestation, which includes slow, shuffling, and stiff movements resembling those seen in Parkinson's disease. This occurs due to the blockade of dopamine receptors in the brain.
Choice A, serpentine limb movement, is not a typical manifestation of pseudo parkinsonism. Choice C, nonreactive pupils, is more indicative of a possible neurological issue. Choice D, smacking lips, is a manifestation of tardive dyskinesia, not pseudo parkinsonism.
The client asks the nurse if the medication can be given 2 hr. earlier. Which of the following statements should the nurse make?
- A. I can start the medication 30 minutes earlier.
- B. I can adjust the time and schedule for when it's convenient for you.
- C. I can infuse the medication at a faster rate.â€
- D. I have up to 2 hours after the usual schedule time to give you this medication.â€
Correct Answer: D
Rationale: The correct answer is D because it adheres to safe medication administration practices. The nurse should explain to the client that there is a window of up to 2 hours after the usual schedule time to administer the medication safely. This ensures that the medication remains effective while also preventing any potential harm from giving it too early or too late.
Choice A is incorrect because starting the medication 30 minutes earlier may not fall within the safe administration window. Choice B is incorrect because adjusting the time solely based on convenience may compromise the medication's effectiveness. Choice C is incorrect because infusing the medication at a faster rate could lead to adverse effects.
Which of the following information should the nurse include?
- A. Information Technology will install a firewall to secure client information
- B. You will be asked to change your password once per year.
- C. Documentation of sensitive material is performed by the charge nurse.
- D. You will be given access to the medical records of every client in the facility.
Correct Answer: A
Rationale: Firewalls help protect sensitive client information in electronic health records.
Which of the following findings should the nurse include in the teaching?
- A. Swelling of the face
- B. Bleeding gums
- C. Urinary frequency
- D. Faintness upon rising
Correct Answer: A
Rationale: Facial swelling may indicate preeclampsia requiring prompt evaluation.