Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8
hours. The nurse inserts the catheter, but no u... [Show More] rine is seen in the tubing. Which action will the nurse take
next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another catheter.
D. Notify the health care provider of a possible obstruction. - Answer: C
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in
place will help locate the meatus when attempting the second catheterization (C). The client should
have at least 240 mL of urine after 8 hours. (A) does not resolve the problem. (B) will not change the
location of the catheter unless it is completely removed, in which case a new catheter must be used.
There is no evidence of a urinary tract obstruction if the catheter could be easily inserted (D).
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a
heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to
this client?
A. "Monitoring Your Blood Pressure at Home"
B. "Smoking Cessation as a Lifelong Commitment"
C. "Decreasing Cholesterol Levels Through Diet"
D. "Stress Management for a Healthier You" - Answer: C
A health promotion brochure about decreasing cholesterol (C) is most important to provide this client,
because the most significant risk factor contributing to development of arteriosclerosis is excess dietary
fat, particularly saturated fat and cholesterol. (A) does not address the underlying causes of
arteriosclerosis. (B and D) are also important factors for reversing arteriosclerosis but are not as
important as lowering cholesterol (C).
Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will
be coming to get me soon!" and falls asleep. Which action should the nurse implement next?
A. Make the client comfortable and allow the client to sleep.
B. Assess the client's neurologic status.
C. Notify the surgeon about the comment.
D. Ask the client's family to co-sign the operative permit. - Answer: B
This statement may indicate that the client is confused. Informed consent must be provided by a
mentally competent individual, so the nurse should further assess the client's neurologic status (B) to be
sure that the client understands and can legally provide consent for surgery. (A) does not provide
sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified (C)
and permission obtained from the next of kin (D).
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent
complications of immobility. Which intervention should be included in this instruction?
A. Perform range-of-motion exercises to prevent contractures.
B. Decrease the client's fluid intake to prevent diarrhea.
C. Massage the client's legs to reduce embolism occurrence.
D. Turn the client from side to back every shift. - Answer: A
Performing range-of-motion exercises (A) is beneficial in reducing contractures around joints. (B, C, and
D) are all potentially harmful practices that place the immobile client at risk of complications.
The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he
states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the
priority action for the nurse to take?
A. Check the client's carotid pulse.
B. Encourage the client to get to the toilet.
C. In a loud voice, call for help.
D. Gently lower the client to the floor. - Answer: D
(D) is the most prudent intervention and is the priority nursing action to prevent injury to the client and
the nurse. Lowering the client to the floor should be done when the client cannot support his own
weight. The client should be placed in a bed or chair only when sufficient help is available to prevent
injury. (A) is important but should be done after the client is in a safe position. Because the client is not
supporting himself, (B) is impractical. (C) is likely to cause chaos on the unit and might alarm the other
clients.
A female nurse is assigned to care for a close friend, who says, "I am worried that friends will find out
about my diagnosis." The nurse tells her friend that legally she must protect a client's confidentiality.
Which resource describes the nurse's legal responsibilities?
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient's Bill of Rights
D. ANA Standards of Practice - Answer: B
The State Nurse Practice Act (B) contains legal requirements for the protection of client confidentiality
and the consequences for breaches in confidentiality. (A) outlines ethical standards for nursing care but
does not include legal guidelines. (C and D) describe expectations for nursing practice but do not
address legal implications.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve
insomnia. A week later the client reports that he is still unable to sleep, despite following the same
routine every night. Which action should the nurse take first?
A. Instruct the client to add regular exercise as a daily routine.
B. Determine if the client has been keeping a sleep diary.
C. Encourage the client to continue the routine until sleep is achieved.
D. Ask the client to describe the routine that the client is currently following. - Answer: D
The nurse should first evaluate whether the client has been adhering to the original instructions (D). A
verbal report of the client's routine will provide more specific information than the client's written diary
(B). The nurse can then determine which changes need to be made (A). The routine practiced by the
client is clearly unsuccessful, so encouragement alone is insufficient (C).
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the
sacral area. Which instruction is most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair. - Answer: B
The most important teaching is to change positions frequently (B) because pressure is the most
significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake (A
and C) may also be beneficial promote healing and reduce further risk. (D) is an intervention of last
resort because this will be very expensive for the client.
When turning an immobile bedridden client without assistance, which action by the nurse best ensures
client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly. - Answer: B
Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to
ensure that the client does not fall out of bed (B). (A) can cause client injury to the skin or joint. (C and
D) are useful techniques while turning a client but have less priority in terms of safety than use of the
bed rails.
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice
about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse provide?
A. Orange juice has vitamin C that deters bacterial growth.
B. Apple juice is the most useful in acidifying the urine.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics. - Answer: C
Cranberry juice (C) maintains urinary tract health by reducing the adherence of Escherichia coli bacteria
to cells within the bladder. (A, B, and D) have not been shown to be as effective as cranberry juice (C) in
preventing UTIs.
The nurse is aware that malnutrition is a common problem among clients served by a community health
clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein
malnutrition?
A. Low serum albumin level
B. Low serum transferrin level
C. High hemoglobin level
D. High cholesterol level - Answer: A
Long-term protein deficiency is required to cause significantly lowered serum albumin levels (A).
Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are
available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. (B)
is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency.
Neither (C or D) are clinical measures of protein malnutrition.
The nurse identifies a potential for infection in a patient with partial-thickness (second-degree) and fullthickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk
of infection?
A. Administration of plasma expanders
B. Use of careful hand washing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns - Answer: B [Show Less]
