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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The nurse assists with data collection during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply.
- A. A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week.
- B. I am proud that I was able to lose 10 lb, but I'm still considered obese for my height.
- C. I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently.
- D. I have struggled with daily episodes of acid reflux for years, especially at nighttime.
- E. I snack on a lot of salted foods like popcorn and peanuts.
Correct Answer: A,C,D
Rationale: Smoking cigars (A), heavy alcohol use (C), and chronic acid reflux (D) are established risk factors for esophageal cancer. Obesity (B) is a weaker risk, and salted foods (E) are not directly linked.
While assisting a client with AM care, the nurse notes small elevated skin lesions less than $0.5 \mathrm{cm}$ in diameter over the client's back. The nurse should describe the lesions as:
- A. Macules
- B. Plaques
- C. Wheals
- D. Papules
Correct Answer: D
Rationale: Papules are small, elevated skin lesions less than 0.5 cm in diameter, matching the description provided.
An adult is prescribed sulfisoxazole (Gantrisin) for a urinary tract infection. Which comment by the client indicates understanding of the treatment regimen?
- A. When I feel better, I can stop taking the medicine.
- B. I will stay out of the sun when I am taking this drug.
- C. I should restrict fluids during the evening as long as I am on the medicine.
- D. I will bring in a urine specimen every day while I am taking the drug.
Correct Answer: B
Rationale: Sulfisoxazole causes photosensitivity; avoiding sun exposure is critical to prevent skin reactions, indicating understanding.
The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply.
- A. Assisting clients with bathing and hair care
- B. Evaluating safety hazards in clients' rooms
- C. Monitoring clients for behavioral changes
- D. Placing bed alarms at night for clients at risk for wandering
- E. Reporting a client's swallowing difficulties during mealtime
Correct Answer: A,D,E
Rationale: Bathing/hair care (A), placing bed alarms (D), and reporting swallowing issues (E) are within UAP scope. Evaluating hazards (B) and monitoring behavior changes (C) require nursing judgment.
The nurse's neighbor calls the nurse and asks for assistance with her child who developed a nosebleed after being hit in the nose by a ball. What should the nurse recommend to the neighbor?
- A. Pinch the child's nose and bend the head forward.
- B. Pinch the child's nose and bend the head backward.
- C. Put ice on the nose and call 911 immediately.
- D. Stuff cotton up both nostrils and bend the head backward.
Correct Answer: A
Rationale: Pinching the nose and leaning forward compresses the bleeding site and prevents blood swallowing, effectively managing a nosebleed caused by trauma.