Nokea
The urinary drainage of a client with continuous bladder irrigation is becoming increasingly red. Which intervention should the nurse implement?
- A. Increase the irrigation rate
- B. Lower the head of the bed
- C. Milk the catheter tubing
- D. Evaluate for fluid overload
Correct Answer: A
Rationale: Increasing the irrigation rate can help clear any blood clots and reduce the redness in the urinary drainage. This intervention aims to improve the flushing of the bladder and potentially resolve the issue. Lowering the head of the bed would not directly address the red urinary drainage. Milking the catheter tubing is not recommended as it can cause trauma to the catheter or bladder, leading to further complications. While evaluating for fluid overload is an important nursing consideration, it does not directly address the immediate concern of redness in the urinary drainage, which requires a focused intervention to clear any blockages or clots in the system.
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The healthcare provider is evaluating a client for potential dehydration. Which assessment finding is most indicative of fluid volume deficit?
- A. Moist mucous membranes
- B. Increased urine output
- C. Decreased skin turgor
- D. Elevated blood pressure
Correct Answer: C
Rationale: Corrected Rationale: Decreased skin turgor is a classic sign of dehydration. When someone is dehydrated, the skin loses its elasticity and becomes less turgid. This change is easily assessed by gently pinching and pulling up the skin on the back of the hand or forearm. If the skin remains elevated or tents rather than quickly returning to its normal position, it indicates dehydration. Moist mucous membranes (Choice A) are actually a sign of adequate hydration. Increased urine output (Choice B) can be a sign of dehydration, but decreased skin turgor is a more specific indicator. Elevated blood pressure (Choice D) is not typically associated with fluid volume deficit and may indicate other health issues.
An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)
- A. 0.4
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Identify the placement of the stapes footplate into the bony labyrinth.
- A. Fenestra vestibuli
- B. Fenestra cochleae
- C. Tympanic membrane
- D. Round window
Correct Answer: A
Rationale: The correct answer is A: Fenestra vestibuli. The stapes footplate is placed into the fenestra vestibuli of the bony labyrinth. This structure is also known as the oval window and is located at the junction of the middle ear and inner ear. Choice B, Fenestra cochleae, is incorrect as this opening is also known as the round window and is located near the base of the cochlea. Choice C, Tympanic membrane, is incorrect as it is also known as the eardrum and separates the external ear from the middle ear. Choice D, Round window, is incorrect as it is the opening covered by the secondary tympanic membrane and is important for the dissipation of sound waves in the cochlea.
A client with eczema is experiencing severe pruritus. Which PRN prescription should the nurse administer?
- A. Topical corticosteroid
- B. Topical scabicide
- C. Topical alcohol rub
- D. Transdermal analgesic
Correct Answer: A
Rationale: The correct answer is A: Topical corticosteroid. Topical corticosteroids are commonly used to manage itching in eczema by reducing inflammation and suppressing the immune response. In this case, for severe pruritus in eczema, a topical corticosteroid would be appropriate. Choice B, Topical scabicide, is used to treat scabies, not eczema. Choice C, Topical alcohol rub, is not typically used to manage pruritus in eczema. Choice D, Transdermal analgesic, is more for pain relief and not specifically targeted at managing itching associated with eczema.
What action should the nurse implement for a female client with cancer who has a good appetite but experiences nausea whenever she smells food cooking?
- A. Encourage family members to cook meals outdoors and bring the cooked food inside
- B. Advise the client to replace cooked foods with a variety of different nutritional supplements
- C. Assess the client's mucus membranes and report the findings to the healthcare provider
- D. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting
Correct Answer: A
Rationale: The correct action for the nurse to implement is to encourage family members to cook meals outdoors and bring the cooked food inside. This strategy can help reduce the smell of cooking food and potentially alleviate the client's nausea triggered by food smells. Assessing the client's mucus membranes (choice C) is not directly related to the client's symptom of nausea triggered by food smells. Instructing the client to take an antiemetic before every meal (choice D) may not address the root cause of the issue, which is the smell of cooking food. Advising the client to replace cooked foods with nutritional supplements (choice B) does not address the immediate problem of food odors triggering nausea.