Nokea
The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter?
- A. Ensure the client understands the procedure prior to implementation
- B. Maintain a sterile field and keep the urinary catheter sterile
- C. Place the catheter supply kit between the client's legs in the center of the bed
- D. Throw swabs used to clean the perineum directly into the biohazard bin
Correct Answer: B
Rationale: Maintaining a sterile field (B) is critical to prevent infection, especially in a disoriented client. Explaining the procedure (A) is ideal but not feasible, kit placement (C) is secondary, and swab disposal (D) follows insertion.
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An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
- A. Review the client's weight pattern over the year
- B. Ask the mother to record her diet for the last 24 hours
- C. Encourage her to talk about her view of herself
- D. Give her several pamphlets on postpartum nutrition
Correct Answer: C
Rationale: Encourage her to talk about her view of herself. To an adolescent, body image is very important, and addressing this concern first facilitates further assessment.
Which behavioral characteristic describes the domestic abuser?
- A. Alcoholic
- B. Over confident
- C. High tolerance for frustrations
- D. Low self-esteem
Correct Answer: D
Rationale: Low self-esteem. Batterers were usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, and have a great need to exercise control or power over their partners.
An adult is scheduled for a paracentesis. What should the nurse plan to do immediately before the procedure is started?
- A. Give the client a full glass of water
- B. Have the client empty his/her bladder
- C. Ask the client to empty his/her bowels
- D. Administer diazepam (Valium) as ordered
Correct Answer: B
Rationale: Emptying the bladder before paracentesis prevents accidental puncture of the bladder during needle insertion into the abdominal cavity. Water intake, bowel emptying, or sedation are not immediate pre-procedure priorities.
The nurse is caring for a client who is receiving antibiotic therapy and develops Clostridioides difficile colitis. Which of the following infection-control precautions should the nurse implement? Select all that apply.
- A. Disinfect surfaces using a diluted bleach solution
- B. Perform hand hygiene using an alcohol-based hand sanitizer
- C. Wear a face mask
- D. Wear a protective gown
- E. Wear nonsterile gloves
Correct Answer: A,D,E
Rationale: Bleach disinfection (A), gowns (D), and gloves (E) are required for C. difficile, which is spore-forming. Alcohol sanitizers (B) are ineffective against spores, and masks (C) are not routinely needed.
A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation?
- A. 10 mg isosorbide dinitrate twice daily
- B. 20 mg atorvastatin once daily
- C. 500 mg naproxen twice daily
- D. 2,000 mg fish oil once daily
Correct Answer: C
Rationale: Naproxen (C), an NSAID, increases cardiovascular risk and bleeding, requiring investigation in coronary artery disease. Isosorbide (A), atorvastatin (B), and fish oil (D) are appropriate.