Question

A nurse is planning care for a client who was admitted to the unit for pneumonia.

Answer 1

Correct Answers

Blank 1 Correct Option: clean the urethral meatus with antiseptic
Blank 2 Correct Option: slowly insert the catheter through the urethral meatus

Rationale :

🧴Cleaning the urethral meatus with antiseptic prevents ascending infections by reducing microbial presence.

🧪Inserting the catheter slowly ensures minimal trauma and confirms sterile technique is maintained during catheterization.

⚠️This stepwise approach aligns with aseptic protocols and prevents catheter-associated urinary tract infections (CAUTIs).

🧼These practices are critical especially in clients with urinary retention, as seen with the 480 mL bladder scan finding.

📌Core Message

Proper aseptic sequence during catheterization is essential to prevent infection and trauma in clients with urinary retention.

Answer 2

Correct Answers

Blank 1 Correct Option: Deep vein thrombosis
Blank 2 Correct Option: Immobility

Rationale :

💁‍♂️Immobility after a stroke significantly reduces venous return, increasing the risk of DVT, especially in lower extremities.

🛏️The new finding of swelling and tenderness in the calf supports venous stasis and possible clot formation.

🧬Although labs like platelets and prealbumin are within safe ranges, the primary issue is circulatory stasis.

🩺Prompt recognition is essential to prevent complications like pulmonary embolism, a life-threatening condition.

📌Core Message

Immobility after stroke leads to venous stasis, which increases the risk of deep vein thrombosis.

Answer 3

Correct Answers

Blank 1 Correct Option: Client 3
Blank 2 Correct Option: Client 4

Rationale :

🌬️Client 3 has pulmonary edema, which is a life-threatening condition and indicates fluid overload, needing urgent respiratory support.

🧪Client 4 has hypokalemia (K⁺ 3.4 mEq/L) and is receiving furosemide, which can worsen electrolyte imbalance, leading to dysrhythmias.

📉These conditions demand priority assessment as they can rapidly deteriorate into cardiac or respiratory emergencies.

⏱️Early detection can prevent further complications, aligning with ABC prioritization.

📌Core Message

Clients with fluid overload and electrolyte disturbances should be assessed first due to potential life-threatening complications.

Answer 4

Correct Answers

Blank 1 Correct Option: Oxygen saturation
Blank 2 Correct Option: Behavioral findings

Rationale :

📉Oxygen saturation drop to 90% despite oxygen therapy may suggest hypoxemia or early signs of hypovolemic shock post-op.

😟Client’s agitation and “feeling something is wrong” are behavioral changes, often early signs of deteriorating perfusion or oxygenation.

💉The blood loss of 1,200 mL and Hgb 8.3 g/dL place the client at risk for hypoxia and decreased tissue oxygenation.

⚠️These findings require immediate intervention to prevent clinical decompensation.

📌Core Message

Agitation and decreased oxygen saturation are early indicators of postoperative hypoxia or blood loss complications.

Answer 5

Correct Answers

Blank 1 Correct Option: Constipation
Blank 2 Correct Option: opioid use

Rationale :

💊Opioids, such as oxycodone, slow gastrointestinal motility, increasing the risk of constipation postoperatively.

🪑This is a common side effect and must be monitored, especially in patients recovering from hip surgery who may have limited mobility.

💤Sedation and immobility further aggravate the issue, making bowel care essential.

⚠️Prophylactic measures like stool softeners are often required to prevent bowel obstruction or discomfort.

📌Core Message

Opioid use increases the likelihood of constipation, especially in immobile postoperative clients.

Answer 6

Correct Answers

Blank 1 Correct Option: Atelectasis
Blank 2 Correct Option: Paralytic ileus

Rationale :

🌬️Shallow breathing post-op places the client at risk for atelectasis, particularly without incentive spirometry.

🍽️Hypoactive bowel sounds and narcotic use can result in paralytic ileus, a serious post-op GI complication.

💤Drowsiness and reduced mobility further impair lung expansion and GI motility, making prevention strategies vital.

📉Early detection of these issues supports recovery and prevents worsening complications.

📌Core Message

Postoperative immobility and opioid use put the client at risk for both atelectasis and paralytic ileus.

Answer 7

Correct Answers:

Decreased bladder tone can cause urinary retention.

Rationale :

🧓In older adults, bladder muscle tone decreases, reducing contractility, which leads to urinary retention.

💦This retention can promote bacterial growth and increase the likelihood of UTIs.

🔁Residual urine is often left behind after voiding, providing a medium for pathogen multiplication.

⚠️Addressing urinary incontinence or retention early reduces the burden of recurrent infections.

📌Core Message

Decreased bladder tone in older adults can lead to urinary retention, increasing the risk for UTIs.

Answer 8

Correct Answers:

Providing care for greater than 1 year

Rationale :

🧓Prolonged caregiving, particularly for more than 1 year, increases the risk of caregiver fatigue, emotional distress, and even chronic illness due to cumulative stress.

💔Chronic caregiving often leads to role strain, neglect of personal health, and burnout, especially without adequate social support.

📉Caregiver stress can result in poor immune function, depression, and decreased quality of life, placing both the caregiver and client at risk.

🧠This highlights the need for interventions like respite care, counseling, and health assessments for long-term caregivers.

📌Core Message

Long-term caregiving significantly increases a family caregiver’s emotional and physical health risks.

Answer 9

Correct Answers:

Secure loose cords in stockinette with tape.

Rationale :

⚠️Clients with latex allergies are at high risk for anaphylactic reactions when exposed to latex-containing materials such as elastic cords.

📦Stockinettes provide a latex-free barrier and securing cords with tape prevents exposure to rubber parts, ensuring allergy precautions are followed.

🚫Multidose vials often have latex stoppers, so piercing them repeatedly can introduce latex particles—this option is not safe.

🕑Scheduling surgery last increases exposure risk from residual latex particles in the room from earlier procedures.

📌Core Message

Use latex-free barriers like stockinettes and tape to protect clients with latex allergies during procedures.

Answer 10

Correct Answers:

Informing the family of a deceased client of the client's wish to be an organ donor

Rationale :

🗣️Client advocacy involves upholding the client’s autonomous decisions, even after death, such as respecting wishes to be an organ donor.

🧾The nurse ensures that legal and ethical rights are honored, even when it may be difficult for the family emotionally.

⚖️Advocacy means promoting the client’s preferences, values, and rights when they cannot speak for themselves.

💊While documentation and reporting incidents are important, they are nursing responsibilities, not acts of client advocacy.

📌Core Message

Upholding a deceased client’s organ donation wish is a key act of client advocacy by the nurse.

1 :
A nurse is planning care for a client who was admitted to the unit for pneumonia.

Correct Answers

2 :
A nurse is caring for a client who had a stroke.

Correct Answers

3 :
A nurse in a medical-surgical unit is caring for 6 clients.

Correct Answers

4 :
A nurse is caring for a client on a medical surgical unit.

Correct Answers

5 :
A nurse is caring for a client.

Correct Answers

6 :
A nurse is caring for a client in a medical-surgical unit.

Correct Answers

7 :
A nurse is providing teaching to an older adult client about factors that increase the risk of urinary tract infection. Which of the following information should the nurse include?

8 :
A charge nurse is teaching a group of newly licensed nurses about the health risks for family caregivers of clients who are chronically ill. Which of the following should the nurse include as placing a family caregiver at risk?

9 :
A nurse is preparing a client who has a latex allergy for surgery. Which of the following actions should the nurse plan to take?

10 :
A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates client advocacy?

1 : A nurse is planning care for a client who was admitted to the unit for pneumonia.

Correct Answers

2 : A nurse is caring for a client who had a stroke.

Correct Answers

3 : A nurse in a medical-surgical unit is caring for 6 clients.

Correct Answers

4 : A nurse is caring for a client on a medical surgical unit.

Correct Answers

5 : A nurse is caring for a client.

Correct Answers

6 : A nurse is caring for a client in a medical-surgical unit.

Correct Answers

7 : A nurse is providing teaching to an older adult client about factors that increase the risk of urinary tract infection. Which of the following information should the nurse include?

8 : A charge nurse is teaching a group of newly licensed nurses about the health risks for family caregivers of clients who are chronically ill. Which of the following should the nurse include as placing a family caregiver at risk?

9 : A nurse is preparing a client who has a latex allergy for surgery. Which of the following actions should the nurse plan to take?

10 : A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates client advocacy?

1 :
A nurse is planning care for a client who was admitted to the unit for pneumonia.

2 :
A nurse is caring for a client who had a stroke.

3 :
A nurse in a medical-surgical unit is caring for 6 clients.

4 :
A nurse is caring for a client on a medical surgical unit.

5 :
A nurse is caring for a client.

6 :
A nurse is caring for a client in a medical-surgical unit.

7 :
A nurse is providing teaching to an older adult client about factors that increase the risk of urinary tract infection. Which of the following information should the nurse include?

8 :
A charge nurse is teaching a group of newly licensed nurses about the health risks for family caregivers of clients who are chronically ill. Which of the following should the nurse include as placing a family caregiver at risk?

9 :
A nurse is preparing a client who has a latex allergy for surgery. Which of the following actions should the nurse plan to take?

10 :
A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates client advocacy?