Nokea
The physician has ordered continuous bladder irrigation for a client following a prostatectomy. The nurse should:
- A. Hang the solution 2-3 feet above the client's abdomen
- B. Allow air from the solution tubing to flow into the catheter
- C. Use a clean technique when attaching the solution tubing to the catheter
- D. Clamp the solution tubing periodically to prevent bladder distention
Correct Answer: A
Rationale: Hanging the solution 2-3 feet above the abdomen ensures proper flow by gravity without excessive pressure, maintaining effective irrigation.
You may also like to solve these questions
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
- A. Administer oxygen via nasal cannula
- B. Have narcan (naloxane) available
- C. Prepare to administer blood products
- D. Prepare to do cardioresuscitation
Correct Answer: B
Rationale: Narcan reverses opioid overdose, a potential complication of narcotic use post-surgery.
During which stage of injury repair does the wound show evidence of erythema and edema, and phagocytosis begins?
- A. Proliferation
- B. Inflammation
- C. Hemostasis
- D. Maturation
Correct Answer: B
Rationale: The inflammation stage (B) involves erythema, edema, and phagocytosis as the body responds to injury. Other stages (A, C, D) have different processes.
Which of the following techniques is recommended for removing a tick from the skin?
- A. Grasping the tick with a tissue and quickly jerking it away from the skin
- B. Placing a burning match close the tick and watching for it to release
- C. Using tweezers, grasp the tick close to the skin and pull the tick free using a steady, firm motion
- D. Covering the tick with petroleum jelly and gently rubbing the area until the tick releases
Correct Answer: C
Rationale: Using tweezers to pull the tick steadily minimizes the risk of leaving mouthparts in the skin.
The nurse is caring for a client with a wound with purulent, foul-smelling drainage. A wound culture is ordered. Which describes the correct collection technique?
- A. clean the wound with normal saline before obtaining specimen
- B. allow 24 hours for antibiotic therapy to take effect before sampling
- C. obtain the specimen from the drainage at the bottom of the wound
- D. culture the outer surface around the wound before collecting exudate
Correct Answer: A
Rationale: Cleaning the wound with saline removes surface contaminants, ensuring an accurate culture from viable tissue.
The nurse is making a home visit to an elderly client during the summer. Upon arrival, the nurse notices the refrigerator and freezer doors are open as the client is using both for air conditioning. Which of the following actions by the nurse are most appropriate?
- A. instruct the client to place a fan in front of the freezer to enhance circulation of cool air
- B. hold a meeting with the client and family to advise them of the safety risks of this practice
- C. note this observation in the client's medical record, but do not discuss with the client
- D. report the incident to the nursing supervisor
Correct Answer: B
Rationale: Discussing the risks (e.g., food spoilage, electrical hazards) with the client and family promotes safety and education.