Nokea
The nurse notes that sediment is present in the urine.
- A. Which of the following actions should the nurse take to obtain a sterile urine specimen?
- B. Disconnect the catheter from the collection tubing.
- C. Obtain the specimen from the retention port.
- D. Use the balloon port to obtain the sterile specimen.
- E. Unclamp the collection port below the bag
Correct Answer: B
Rationale: Retention ports allow sterile specimen collection.
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A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys leading to blood in the urine. This is known as hematuria. Polyuria (choice A) is not typically seen in this condition as the kidneys are not able to effectively filter urine. Hypotension (choice B) is unlikely as fluid retention and hypertension are more common due to decreased kidney function. Weight loss (choice C) is not a common finding as the condition often leads to fluid retention. Therefore, hematuria is the most expected finding in acute glomerulonephritis.
Which of the following guidelines should the nurse manager include?
- A. Remove the client's restraint every 4 hr
- B. Document the client's condition every 15 min.
- C. Request a PRN restraint prescription for clients who are aggressive.
- D. Attach the restraint to the bed's side rails.
Correct Answer: B
Rationale: The correct answer is B: Document the client's condition every 15 min. This guideline is crucial to monitor the client's well-being, detect any changes promptly, and ensure the effectiveness of the restraint. Removing the restraint every 4 hours (choice A) can compromise the client's safety and defeat the purpose of using restraints. Requesting a PRN restraint prescription for aggressive clients (choice C) may lead to overuse of restraints without proper assessment. Attaching restraints to the bed's side rails (choice D) can increase the risk of injury and is not recommended. Regular documentation is essential in ensuring the client's safety and well-being.
Which of the following food choices should the nurse include on the client's food tray?
- A. Bacon and cheese quiche with milk
- B. Scrambled eggs and toast with milk
- C. Shrimp salad and tomato soup with milk
- D. Ham sandwich with milk
Correct Answer: B
Rationale: Kosher diets exclude pork and shellfish.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
- A. Irrigate indwelling urinary catheter with 50 mL of normal saline:
- B. Administer enema to relieve constipation
- C. Maintain bed rest for 2 days postoperatively
- D. Place a blanket rob under the client's knees while in bed.
- E. Apply warm compresses to the incision site.
Correct Answer:
Rationale: Rationales provided within the question context.
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- A. Speak slowly when talking to the interpreter.
- B. Pause in the middle of sentences
- C. Speak directly to the client
- D. Use gestures to convey meaning
Correct Answer: C
Rationale: The correct answer is C: Speak directly to the client. This is important because even when using an interpreter, the nurse should maintain eye contact and address the client directly to establish trust and ensure the message is accurately conveyed. Speaking slowly (choice A) may be helpful, but it is not as crucial as direct communication. Pausing in the middle of sentences (choice B) could lead to confusion. Using gestures (choice D) may not always accurately convey the intended message. Therefore, speaking directly to the client is the most effective way to ensure clear communication and understanding.