Nokea
The postoperative male client has been unable to urinate into the urinal while lying in bed. Which interventions are appropriate to promote voiding for this client who is to be discharged home within a few hours? Select all that apply.
- A. Have the client apply an external condom catheter while lying flat in bed
- B. Assist the client to stand at the bedside to attempt to urinate in a urinal.
- C. Administer a prescribed analgesic if the client is experiencing pain.
- D. Turn on running water so it is heard while the client attempts to void.
- E. Ask the client to imagine being at home and voiding in his own bathroom.
Correct Answer: B,C,D,E
Rationale: B: Standing mimics normal voiding position. C: Pain relief aids relaxation for voiding. D: Running water stimulates the voiding reflex. E: Guided imagery promotes relaxation. A: Condom catheters manage incontinence, not promote voiding.
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Which of the following statements from a client may indicate that they are at a higher risk for a fall?
- A. I would like to get out of bed but would like to put on my non-skid socks first.
- B. Can you make sure the two bedrails are raised before leaving the room?
- C. I think I'm ready to walk a longer distance with the cane today.
- D. I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.
Correct Answer: D
Rationale: A client who is visually impaired without their assistive devices could be at a higher risk for a fall when ambulating.
The nurse is using Cognitive-Behavioral methods of pain control and knows that these methods can be expected to do all the following except:
- A. completely relieve all pain.
- B. provide benefit by restoring the client's sense of self-control.
- C. help the client to control symptoms.
- D. help the client actively participate in his or her own care.
Correct Answer: A
Rationale: These interventions (strategies) help the client in all areas of client well-being. Focusing on perception and thought, cognitive techniques are designed to influence how one interprets events and bodily sensations.
Safety measures for using crutches must be taught to clients. Safety measures for the use of crutches include:
- A. properly fitting crutches with rubber tips at the end that provide a four-point gait.
- B. properly fitting crutches, education in the appropriate gait, and strength in the arms.
- C. crutches that fit the way the client chooses and a gait chosen by client.
- D. both legs touching the floor for all gaits.
Correct Answer: B
Rationale: In addition to the rubber tips on the ends of the crutches, the client needs to know the appropriate gait. Arm strength exercises are important, and it is critical that the client be fitted properly for the crutches.
A nurse assesses a 83 year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage and the patient has limited mobility in her home. Which of the options is the best course of action?
- A. Encourage warm water soaks to the right foot.
- B. Notify the case manager of the purulent drainage.
- C. Determine the patient's pulse in the right ankle.
- D. Recommend increased activity to reduce the purulent drainage.
Correct Answer: A
Rationale: A determination of arterial blood flow should be made, prior to encouraging increased activity, or notifying additional team members.
Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?
- A. high protein
- B. high carbohydrate
- C. low carbohydrate
- D. low protein
Correct Answer: A
Rationale: Clients with burns are hypermetabolic and require increased protein levels to maintain a positive nitrogen balance. Choices 2 and 3 are incorrect; carbohydrate levels do not help clients to meet this goal. Choice 4 is incorrect; a client with major burns requires a high-protein diet.