Nokea
When caring for a client with a urinary catheter, what is the most important intervention to prevent infection?
- A. Use sterile technique for catheter care
- B. Ensure the catheter bag is below the level of the bladder
- C. Provide perineal care daily
- D. Change the catheter only when necessary
Correct Answer: B
Rationale: The most important intervention to prevent infection when caring for a client with a urinary catheter is to ensure that the catheter bag is below the level of the bladder. This positioning helps prevent urine backflow, reducing the risk of infection. While using sterile technique for catheter care (Choice A) is important, ensuring proper drainage by keeping the catheter bag below the bladder is crucial to prevent infection. Providing perineal care daily (Choice C) is essential for hygiene but not directly related to preventing catheter-related infections. Changing the catheter only when necessary (Choice D) is important for maintenance, but correct positioning of the catheter bag is more critical in preventing immediate infection.
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When counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse do?
- A. Recheck the radial pulse in thirty minutes
- B. Palpate the radial pulse for thirty seconds and double the rate
- C. Count the apical pulse rate for sixty seconds
- D. Compare the radial pulse rate bilaterally and record the higher rate
Correct Answer: C
Rationale: The correct answer is to count the apical pulse rate for sixty seconds. The apical pulse is more accurate, especially when peripheral pulses are weak or irregular. Counting the apical pulse for a full minute provides a more precise heart rate measurement. Option A is incorrect because waiting for thirty minutes is unnecessary and could delay potential interventions. Option B is incorrect because doubling the radial pulse rate may not provide an accurate representation of the heart rate. Option D is incorrect because comparing radial pulses bilaterally does not give the most accurate heart rate measurement; the apical pulse is preferred in this situation.
The healthcare provider is preparing to administer an IM injection to an adult client. Which site is the preferred location for this injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Ventrogluteal muscle
- D. Dorsogluteal muscle
Correct Answer: C
Rationale: The ventrogluteal site is the preferred site for IM injections in adults due to its muscle mass and low risk of nerve injury. The deltoid muscle, although commonly used for vaccines in adults due to easy accessibility, has a smaller muscle mass making it less ideal for IM injections. The vastus lateralis muscle is typically used in infants and young children, not in adults. The dorsogluteal site has a higher risk of injury to the sciatic nerve and is no longer recommended for IM injections in any age group.
A client with a history of hypertension is prescribed lisinopril. Which potential side effect should the nurse monitor for?
- A. Hypokalemia
- B. Hyperglycemia
- C. Persistent cough
- D. Tachycardia
Correct Answer: C
Rationale: The correct answer is C: Persistent cough. Lisinopril is an ACE inhibitor commonly associated with a persistent dry cough as a side effect. This cough is thought to result from increased bradykinin levels. Choices A, B, and D are incorrect. Hypokalemia is not a common side effect of lisinopril; in fact, it may lead to hyperkalemia. Hyperglycemia is not a typical side effect of lisinopril use. Tachycardia is also not a common side effect associated with ACE inhibitors like lisinopril.
A 9-year-old is receiving vancomycin 400 mg IV every 6 hours for a methicillin-resistant (Beta-lactam-resistant) Staphylococci aureus (MRSA) infection. The medication is diluted in a 100 mL bag of saline with instructions to infuse over one and a half hours. How many mL/hour should the nurse program the infusion pump?
- A. 50
- B. 67
- C. 57
- D. 70
Correct Answer: B
Rationale: To calculate the infusion rate for vancomycin, you need to divide the total volume by the total time of infusion. In this case, the total volume is 100 mL, and the total time is 1.5 hours. Therefore, 100 mL · 1.5 hours = 67 mL/hour. This means the nurse should program the infusion pump to deliver vancomycin at a rate of 67 mL/hour. Choice A (50) is incorrect as it does not reflect the correct calculation. Choice C (57) is incorrect as it is not the accurate calculation based on the provided information. Choice D (70) is incorrect as it does not correspond to the correct infusion rate calculation.
The nurse is assessing a client with left-sided heart failure. Which symptom should the nurse expect to find?
- A. Peripheral edema
- B. Jugular vein distention
- C. Shortness of breath
- D. Weight gain
Correct Answer: C
Rationale: Shortness of breath is a characteristic symptom of left-sided heart failure. In this condition, the heart's inability to effectively pump blood forward causes blood to back up into the lungs, leading to fluid accumulation. This fluid accumulation results in pulmonary congestion, manifesting as shortness of breath or difficulty breathing. Peripheral edema (choice A) is more commonly associated with right-sided heart failure, where fluid accumulates in the extremities. Jugular vein distention (choice B) is a sign of increased central venous pressure and is more indicative of right-sided heart failure. Weight gain (choice D) can be a general symptom of heart failure due to fluid retention, but shortness of breath is specifically related to left-sided heart failure.