Nokea
The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? The student
- A. Applies clean gloves to cleanse the perineal area with soap and water.
- B. Asks the client to bear down as the catheter is slowly inserted through the urethral meatus.
- C. Separates the labia with the fingers of the dominant hand when cleaning with antiseptic solution.
- D. Secures the catheter tubing to the inner thigh.
- E. Attaches the drainage bag to the side rails of bed.
Correct Answer: A,C,E
Rationale: Sterile gloves are required for perineal cleaning, the non-dominant hand holds the labia, and the drainage bag should be attached below the bladder level, not to side rails. Bearing down and securing to the inner thigh are correct.
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The nurse is educating staff on infection control. Which of the following statements by the nurse would indicate a correct understanding of infection control guidelines for influenza? Select all that apply.
- A. Limiting visitation to 30 minutes per day.
- B. Keeping the door to the client's room closed.
- C. Wearing a surgical mask when providing care.
- D. Placing the client in a room at the end of the hall.
- E. Cleaning common surfaces with 70% isopropyl alcohol.
Correct Answer: B,C
Rationale: Influenza requires droplet precautions, including a surgical mask within 3 feet and a closed door to reduce transmission. The other options are not standard for influenza.
The nurse performs a home safety survey for an individual with epilepsy. Click to specify the findings that require intervention by the nurse
- A. Multiple glass tables in the living room
- B. Multiple feather pillows present on the bed
- C. Padded covers on the edges of countertops
- D. Wall-to-wall carpeting was removed and replaced with scattered rugs on hardwood flooring
- E. Kitchen knives were readily accessible
- F. Client reports using the microwave instead of the stove
- G. Locks on the bathroom door
Correct Answer: A,D,E,G
Rationale: Glass tables, scattered rugs, accessible knives, and bathroom locks pose injury risks during seizures, requiring intervention.
The nurse is teaching a client who recently had a femoral vein central line catheter placed. Which of the following information should the nurse include?
- A. You will need to avoid drinking more than 500 mL per day.
- B. You will clean the site daily with soap and water.
- C. You should not sit up more than 45 degrees.
- D. You can remove the dressing if it becomes itchy.
Correct Answer: B
Rationale: Daily cleaning with soap and water maintains hygiene at the femoral central line site. Fluid restriction, angle limitation, and patient removal of dressings are incorrect and unsafe.
The nurse is preparing to provide care for a client with disseminated herpes zoster. The nurse plans to don which personal protective equipment (PPE)? Select all that apply.
- A. Goggles
- B. Gown
- C. Gloves
- D. Shoe covers
- E. N95 respirator
- F. Surgical face mask
Correct Answer: B,C,E
Rationale: Disseminated herpes zoster requires airborne and contact precautions, necessitating a gown, gloves, and N95 respirator. Goggles, shoe covers, and surgical masks are insufficient.
The nurse is caring for a client newly admitted to the medical-surgical unit. Which clinical data is most helpful in assessing the client's fall risk?
- A. observing the client's gait and balance
- B. the client's ability to turn from side to side while in bed
- C. interviewing close family members about the client's gait and balance
- D. the client's self-report on their gait and balance
Correct Answer: A
Rationale: Direct observation of gait and balance provides the most reliable data for assessing fall risk.