Nokea
Which nursing action is most appropriate to carry out the medical order?
- A. Catheterize the client as soon as possible.
- B. Catheterize the client after her next voiding.
- C. Connect the catheter to gravity drainage.
- D. Use a small-gauge catheter to drain the bladder.
Correct Answer: B
Rationale: Catheterizing after the next voiding allows measurement of residual urine, assessing bladder function accurately.
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The client diagnosed with gestational diabetes delivered a 10-pound 5-ounce infant. Which is priority for the nursery nurse to monitor?
- A. Failure to latch on to the breast during feeding.
- B. Jaundice and clay-colored stools.
- C. Parchment-like skin and lack of lanugo.
- D. Low blood glucose readings.
Correct Answer: D
Rationale: Macrosomic infants from gestational diabetes are at risk for hypoglycemia; monitoring blood glucose is priority. Latching issues, jaundice, and skin changes are secondary.
Which instruction is appropriate to include when providing the client with oral contraceptive teaching?
- A. Take oral contraceptives at the same time each day.
- B. Take oral contraceptives on an empty stomach.
- C. Take oral contraceptives on the first day of menses.
- D. Take oral contraceptives in the morning with food.
Correct Answer: A
Rationale: Taking oral contraceptives at the same time daily ensures consistent hormone levels, maximizing efficacy.
Which instruction is best when teaching the client about inserting vaginal medication?
- A. Place the applicator just inside the vaginal opening.
- B. Insert the applicator while sitting on the toilet.
- C. Instill the medication just before retiring for sleep.
- D. Put on disposable latex gloves before applying the drug.
Correct Answer: C
Rationale: Instilling vaginal medication before sleep allows the medication to remain in the vagina longer, increasing its effectiveness.
The nurse is caring for a client newly diagnosed with Stage IV ovarian cancer. What is the scientific rationale for detecting the tumors at this stage?
- A. The client’s ovaries lie deep within the pelvis and early symptoms are vague.
- B. The client has regular gynecological examinations and this helps with detection.
- C. The client had a history of dysmenorrhea and benign ovarian cysts.
- D. The client had a family history of breast cancer and was being checked regularly.
Correct Answer: A
Rationale: Ovarian cancer is often diagnosed at Stage IV due to vague early symptoms and deep pelvic location, delaying detection. Regular exams, dysmenorrhea, or breast cancer history do not ensure early detection.
Which intervention should the nurse include when teaching the client who is having an anterior colporrhaphy to repair a cystocele?
- A. Discuss the need to perform perineal care every four (4) hours.
- B. Discuss the care of an indwelling catheter for at least one (1) month.
- C. Instruct the client how to care for the pessary inserted in surgery.
- D. Teach the client how to perform Kegel exercises.
Correct Answer: D
Rationale: Kegel exercises strengthen pelvic floor muscles, aiding recovery and preventing recurrence post-anterior colporrhaphy. Perineal care frequency is excessive, catheters are temporary, and pessaries are not used surgically.