Nokea
When the nurse mistakenly inserts the catheter into the client's vagina rather than the urinary meatus, which action is best to take next?
- A. Wipe the catheter tip with an alcohol swab.
- B. Clean the catheter tip with povidone-iodine solution (Betadine).
- C. Discard the catheter and use another sterile one.
- D. Withdraw the catheter and insert it in the urethra.
Correct Answer: C
Rationale: Inserting the catheter into the vagina contaminates it, so a new sterile catheter must be used to prevent infection.
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In evaluating multiple clients with UTIs, the clinic nurse should identify which client to be at least risk for developing a UT1?
- A. A client with urethral mucosa damage
- B. A client with an altered mental condition
- C. A client with an altered metabolic state
- D. An immunocompromised client
Correct Answer: C
Rationale: An altered metabolic state, without specific risk factors like diabetes, poses the least risk for UTIs compared to mucosal damage, mental status changes, or immunosuppression.
The nurse is caring for a client with chronic pyelonephritis. Which assessment data support the diagnosis of chronic pyelonephritis?
- A. The client has fever, chills, flank pain, and dysuria.
- B. The client complains of fatigue, headaches, and increased urination.
- C. The client had a group B beta-hemolytic strep infection last week.
- D. The client has an acute viral pneumonia infection.
Correct Answer: B
Rationale: Chronic pyelonephritis presents with subtle symptoms like fatigue, headaches, and polyuria due to long-term renal damage. Acute symptoms (fever, chills) are more typical of acute pyelonephritis. Strep or pneumonia are unrelated.
When the client with an ileal conduit asks about resuming physical activity, which response by the nurse is most appropriate?
- A. Avoid all strenuous activity permanently.
- B. Resume activities gradually as tolerated.
- C. Wait at least 6 months before exercising.
- D. Limit activity to walking only.
Correct Answer: B
Rationale: Resuming activities gradually as tolerated allows the client to regain strength while protecting the stoma.
The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement?
- A. Teach the client to carry heavy objects with the right arm.
- B. Perform all laboratory blood tests on the left arm.
- C. Instruct the client to lie on the left arm during the night.
- D. Discuss the importance of not performing any hand exercises.
Correct Answer: A
Rationale: To protect the new AV fistula, the client should avoid stress on the left arm. Carrying heavy objects with the right arm prevents fistula damage. Blood tests should avoid the fistula arm, lying on it risks compression, and hand exercises are encouraged to promote fistula maturation.
Which nursing intervention is most important to add to the client's care plan after removal of the suprapubic catheter?
- A. Check the client's urine specific gravity every shift.
- B. Measure the client's abdominal girth daily.
- C. Change wet abdominal dressings as needed.
- D. Perform a credé maneuver every 4 hours.
Correct Answer: C
Rationale: Changing wet dressings prevents infection and promotes healing at the suprapubic site.