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When teaching a client how to perform self-catheterization, which of the following instructions should be included?
- A. Use sterile gloves during the procedure.
- B. Clean the catheter with alcohol after each use.
- C. Insert the catheter 2-4 inches into the urethra.
- D. Perform the procedure every 8 hours.
Correct Answer: C
Rationale: To ensure effective drainage, the catheter should be inserted 2-4 inches into the urethra. This length allows the catheter to reach the bladder, bypass the urethral sphincters, and ensure proper drainage without causing discomfort or injury. Using sterile gloves, cleaning the catheter with alcohol, and performing the procedure every 8 hours are not accurate instructions for self-catheterization.
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A client has a pressure ulcer. Which of the following findings indicates healing of the ulcer?
- A. Increase in drainage.
- B. Decrease in size.
- C. Presence of foul odor.
- D. Reddened wound edges.
Correct Answer: B
Rationale: When a pressure ulcer is healing, there is a decrease in its size as the tissue repair progresses. This reduction in size is a positive indication of the healing process. An increase in drainage, presence of foul odor, or reddened wound edges are typically signs of infection or lack of improvement. Therefore, the correct answer is a decrease in size.
A client with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage pursed-lip breathing.
- B. Administer oxygen at 6 L/min via nasal cannula.
- C. Place the client in a supine position.
- D. Restrict fluid intake to less than 1,500 mL/day.
Correct Answer: A
Rationale: Encouraging pursed-lip breathing is essential for clients with COPD as it aids in improving ventilation and gas exchange. This technique helps keep the airways open longer during exhalation, preventing air trapping and promoting more effective breathing. Administering oxygen, placing the client in a supine position, or restricting fluid intake are not primary interventions for managing COPD and may not address the specific respiratory needs of the client.
When caring for a client with a prescription for wound irrigation, which action should the nurse take?
- A. Use a 10-mL syringe with an 18-gauge needle.
- B. Cleanse the wound from the center outward.
- C. Apply a wet-to-dry dressing.
- D. Pack the wound tightly with gauze.
Correct Answer: B
Rationale: When caring for a client with a prescription for wound irrigation, the nurse should cleanse the wound from the center outward. This technique helps prevent the introduction of microorganisms into the wound, reducing the risk of contamination and promoting effective wound healing. By using a circular motion from the cleanest area to the least clean areas, debris and bacteria are moved away from the wound site, decreasing the chances of infection.
A healthcare professional is assessing a client who has fluid volume overload. Which of the following findings should the healthcare professional expect?
- A. Hypotension.
- B. Bradycardia.
- C. Crackles in the lungs.
- D. Flat neck veins.
Correct Answer: C
Rationale: Crackles in the lungs are a classic sign of fluid volume overload. When there is an excess of fluid in the lungs, it can manifest as crackling sounds upon auscultation. This finding indicates the accumulation of fluid in the alveoli and interstitial spaces of the lungs, which is a common manifestation of fluid volume overload.
When educating a client on the proper use of a metered-dose inhaler (MDI), which of the following instructions should be included?
- A. Shake the inhaler before use.
- B. Inhale quickly and deeply.
- C. Use the inhaler as needed.
- D. Do not use a spacer with the inhaler.
Correct Answer: A
Rationale: Shaking the inhaler before use is crucial to ensure proper mixing of the medication. This action helps distribute the medication evenly, allowing for consistent dosing with each use. It is a vital step in using a metered-dose inhaler correctly to optimize its effectiveness in managing respiratory conditions.