Nokea
The physician has ordered a sterile urine specimen to be collected from a client who has a Foley catheter. To obtain a sterile urine specimen, the nurse should:
- A. Use a luer lock syringe and withdraw from the bulb port.
- B. Disconnect the catheter from the drainage bag.
- C. Open the urine bag and remove the specimen.
- D. Use a syringe and withdraw from the catheter port.
Correct Answer: D
Rationale: Withdrawing from the catheter port with a syringe ensures a sterile specimen. Other methods risk contamination.
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The registered nurse and practical nurse are conducting a workshop on contraceptive methods for a group of outpatient clients. Which instructions should the nurses include when discussing combined estrogen-progestin oral contraceptives? Select all that apply.
- A. Consult the health care provider (HCP) if you experience leg pain or swelling
- B. Discontinue contraceptives if you experience spotting between menses
- C. Do not smoke while taking combined contraceptives
- D. Immediately report any breast tenderness to the HCP
- E. Seek immediate medical treatment if you experience vision loss
Correct Answer: A,C,E
Rationale: For combined oral contraceptives: report leg pain/swelling for possible DVT; avoid smoking due to increased cardiovascular risk; and seek treatment for vision loss indicating possible stroke. Spotting is common and breast tenderness is not urgent.
The physician has recommended that the client increase the amount of dietary iron. The nurse knows that the client understands the recommendation when the client selects which foods?
- A. Orange juice, scrambled eggs, and toast
- B. Hot dog and roll, French fries, and cola
- C. Roast beef, carrots, and rice
- D. Baked chicken, peas, and noodles
Correct Answer: C
Rationale: Roast beef is high in iron, suitable for increasing dietary iron. Other options lack significant iron sources.
In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord protrudes from the vagina. What is the priority nursing action?
- A. call the health care provider
- B. check fetal heart load
- C. put the client in knee-chest position
- D. turn the client to the side
Correct Answer: C
Rationale: Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The knee-chest position accomplishes this. The exposed cord is covered with saline-soaked gauze, not reinserted.
The drug of choice for managing status epilepticus is:
- A. Carbamazepine (Tegretol)
- B. Diazepam (Valium)
- C. Clonazepam (Klonopin)
- D. Valproic acid (Depakene)
Correct Answer: B
Rationale: Diazepam is the first-line treatment for status epilepticus due to its rapid onset in stopping seizures.
The postoperative client on hydrocodone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?
- A. Client's respiratory status 60 minutes later
- B. Documenting the client's hypoxic event
- C. Obtaining an order for a different analgesic
- D. Potential for drug-drug interaction now
Correct Answer: A
Rationale: After naloxone administration for opioid-induced hypoxia, monitoring respiratory status is critical as naloxone's effects are short-acting, and respiratory depression may recur. Documentation is important but secondary, changing analgesics is not immediate, and drug interactions are less urgent.