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Terms in this set (74)
Urinary catheterization is Answer: C
prescribed for a It is likely that the first catheter is in the vagina, rather
postoperative female than the bladder. Leaving the first catheter in place
client who has been will help locate the meatus when attempting the
unable to void for 8 hours. second catheterization (C). The client should have at
The nurse inserts the least 240 mL of urine after 8 hours. (A) does not
catheter, but no urine is resolve the problem. (B) will not change the location
seen in the tubing. Which of the catheter unless it is completely removed, in
action will the nurse take which case a new catheter must be used. There is no
next? evidence of a urinary tract obstruction if the catheter
A. Clamp the catheter and could be easily inserted (D).
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.
,The nurse is teaching an Answer: C
obese client, newly A health promotion brochure about decreasing
diagnosed with cholesterol (C) is most important to provide this
arteriosclerosis, about client, because the most significant risk factor
reducing the risk of a contributing to development of arteriosclerosis is
heart attack or stroke. excess dietary fat, particularly saturated fat and
Which health promotion cholesterol. (A) does not address the underlying
brochure is most causes of arteriosclerosis. (B and D) are also
important for the nurse to important factors for reversing arteriosclerosis but are
provide to this client? not as important as lowering cholesterol (C).
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"
,Ten minutes after signing Answer: B
an operative permit for a This statement may indicate that the client is confused.
fractured hip, an older Informed consent must be provided by a mentally
client states, "The aliens competent individual, so the nurse should further
will be coming to get me assess the client's neurologic status (B) to be sure that
soon!" and falls asleep. the client understands and can legally provide
Which action should the consent for surgery. (A) does not provide sufficient
nurse implement next? follow-up. If the nurse determines that the client is
A. Make the client confused, the surgeon must be notified (C) and
comfortable and allow the permission obtained from the next of kin (D).
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.
, The nurse-manager of a Answer: A
skilled nursing (chronic Performing range-of-motion exercises (A) is beneficial
care) unit is instructing in reducing contractures around joints. (B, C, and D)
UAPs on ways to prevent are all potentially harmful practices that place the
complications of immobile client at risk of complications.
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.