Nokea
When applying an external catheter to a male client, which action by the nurse is correct?
- A. I think the nurse is correct applying the catheter.
- B. Measure the length and circumference of the penis.
- C. Leave space between the end of the penis and the catheter's drainage end.
- D. Retract the foreskin before rolling the catheter sheath over the penis.
Correct Answer: C
Rationale: Leaving space between the penis and the catheter's drainage end prevents pressure and irritation, ensuring proper function and comfort.
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The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first?
- A. The client in normal sinus rhythm with a peaked T wave.
- B. The client diagnosed with atrial fibrillation with a rate of 100.
- C. The client diagnosed with a myocardial infarction who has occasional PVCs.
- D. The client with a first-degree atrioventricular block and a rate of 92.
Correct Answer: A
Rationale: Peaked T waves indicate hyperkalemia, which can lead to life-threatening arrhythmias, requiring immediate assessment. Atrial fibrillation, PVCs, and first-degree AV block are less urgent unless unstable.
When the client complains about the bland taste of the food, the nurse appropriately recommends substituting salt with a bloodiness?
- A. Catsup
- B. Mustard
- C. Soy sauce
- D. Lemon juice
Correct Answer: D
Rationale: Lemon juice is a low-sodium flavor enhancer, suitable for a sodium-restricted diet, unlike catsup, mustard, or soy sauce.
The client with a history of renal calculi calls the clinic and reports having burning on urination, chills, and an elevated temperature. Which instruction should the nurse discuss with the client?
- A. Increase water intake for the next 24 hours.
- B. Take two (2) Tylenol to help decrease the temperature.
- C. Come to the clinic and provide a urinalysis specimen.
- D. Use a sterile 4×4 gauze to strain the client’s urine.
Correct Answer: C
Rationale: Burning, chills, and fever suggest a UTI, possibly related to calculi. A urinalysis specimen is needed to diagnose and guide treatment. Increasing fluids, taking Tylenol, or straining urine are secondary.
Which diagnostic test, considered a sensitive indicator of advanced kidney disease, will need to be closely monitored by the nursing team?
- A. Serum creatinine level
- B. Serum sodium level
- C. Uric acid level
- D. Urine specific gravity
Correct Answer: A
Rationale: Serum creatinine is a sensitive indicator of kidney function, as it rises with advanced kidney disease due to impaired filtration.
Which nursing intervention is most important before attempting to catheterize a client?
- A. Determine the client’s history of catheter use.
- B. Evaluate the level of anxiety of the client.
- C. Verify the client is not allergic to latex.
- D. Assess the client’s sensation level and ability to void.
Correct Answer: C
Rationale: Verifying latex allergy prevents allergic reactions during catheterization, as many catheters are latex-based. Catheter history, anxiety, and sensation/voiding ability are important but secondary to safety.