Nokea
The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate?
- A. The client has acute urinary retention
- B. The client is confused and incontinent
- C. The client is elderly and at risk for falls
- D. The client is receiving intravenous diuretics
Correct Answer: A
Rationale: Acute urinary retention (A) is a medical indication for catheterization. Confusion/incontinence (B), fall risk (C), and diuretics (D) are not sufficient justifications.
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The nurse is assisting with the admission of a client who attempted suicide after being diagnosed with end-stage kidney disease. It would be a priority for the nurse to
- A. assign the client a private room near the nurses' station
- B. explore the client's feelings about the diagnosis
- C. initiate continuous one-to-one observation
- D. perform a mental status examination
Correct Answer: C
Rationale: Continuous one-to-one observation (C) is the priority to ensure safety after a suicide attempt. Room assignment (A), exploring feelings (B), and mental status exam (D) are secondary.
The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time?
- A. Client admitted with Guillain-Barré syndrome yesterday is paralyzed to the knees
- B. Client admitted with multiple sclerosis exacerbation has scanning speech
- C. Client with epilepsy puts on call light and reports having an aura
- D. Client with fibromyalgia reports pain in the neck and shoulders
Correct Answer: C
Rationale: An aura (C) indicates an impending seizure, requiring immediate intervention to ensure safety. Guillain-Barré (A), multiple sclerosis (B), and fibromyalgia (D) are less acute at this moment.
A client is being discharged after having a coronary artery bypass grafting x5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply.
- A. Report any itching, tingling, or numbness around your incisions
- B. Report any redness, swelling, warmth, or drainage from your incisions
- C. Soak incisions in the tub once a week, then clean with hydrogen peroxide and apply lotion
- D. Wash incisions daily with soap and water in the shower and gently pat them dry
- E. Wear an elastic compression hose on your legs and elevate them while sitting
Correct Answer: A, B, D
Rationale: Reporting sensory changes (A), signs of infection (B), and washing gently (D) promote healing. Soaking and peroxide (C) can disrupt healing, and compression hose (E) are not routinely needed.
The nurse enters an infant's room and observes that the infant is responsive but is choking and turning blue. Which of the following actions should the nurse take?
- A. Initiate CPR
- B. Perform abdominal thrusts.
- C. Initiate back slaps and chest thrusts.
- D. Perform a blind sweep of the infant's mouth.
Correct Answer: C
Rationale: Back slaps and chest thrusts (C) are the appropriate intervention for a choking infant. CPR (A) is for cardiac arrest, abdominal thrusts (B) are for older children, and blind sweeps (D) are dangerous.
Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?
- A. I know there is a problem since my baby is always constipated.
- B. My child doesn't like many fruits and vegetables, but she really loves her milk.
- C. My child is not eating as much as she did 4 months ago.
- D. My child doesn't drink a whole glass of juice or water at 1 time.
Correct Answer: B
Rationale: My child doesn't like many fruits and vegetables, but she really loves her milk. Excessive milk intake can displace iron-rich foods, leading to iron deficiency anemia.