Question

A nurse is caring for a female client who is postoperative and is having difficulty urinating after the removal of an indwelling urinary catheter. Which of the following techniques should the nurse teach the client to use to promote urination?

Answer 1

Correct Answers:

Pouring warm water over the perineum

Rationale :

💠Postoperative urinary retention is common after catheter removal due to decreased bladder tone and anesthesia effects.

💠Pouring warm water stimulates the micturition reflex by relaxing the urethral sphincter and perineal muscles.

💠The warmth increases local blood flow and provides a sensory stimulus that triggers the urge to void.

💠Noninvasive measures like this are always attempted before invasive interventions such as catheter reinsertion.

💠This technique promotes comfort, bladder emptying, and reduces infection risk compared to prolonged retention.

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Answer 2

Correct Answers:

Ensure the client has advance directives on file.

Rationale :

🔶Clients with stage 4 cancer face significant treatment decisions, making advance directives essential for guiding future care.

🔶Advance directives provide legal documentation of the client’s wishes regarding life-sustaining treatments.

🔶This ensures autonomy and self-determination by respecting the client’s right to make choices about their care.

🔶Nurses are responsible for verifying and facilitating the completion of such documents during admission.

🔶Having directives on file also provides clarity for the interdisciplinary team and family members, reducing conflict in critical situations.

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Answer 3

Correct Answers:

Auscultate bowel sounds.

Rationale :

🟡Clients with right lower quadrant pain, nausea, and vomiting may have appendicitis or other acute abdominal conditions.

🟡The first step in assessment is to auscultate bowel sounds before palpating, as palpation may cause rupture or worsen pain.

🟡Early auscultation helps detect obstruction, ileus, or peritonitis signs.

🟡This is a priority assessment because it provides baseline information for surgical decision-making.

🟡Delaying this step may compromise safe and accurate diagnosis of abdominal emergencies.

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Answer 4

Correct Answers:

The Consider gender and age when selecting an interpreter.

Rationale :

🔷Effective communication requires sensitivity to cultural, age, and gender dynamics.

🔷Clients may not feel comfortable discussing personal health with an interpreter of the opposite gender.

🔷Selecting an appropriate interpreter ensures trust, openness, and accurate communication.

🔷It also respects the client’s cultural norms and privacy, promoting dignity in care.

🔷This action reduces the risk of misinterpretation and improves client outcomes.

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Answer 5

Correct Answers:

Heart failure

Rationale :

♦ Obstructive sleep apnea (OSA) causes repeated nighttime hypoxia and hypercapnia.

♦ These changes increase pulmonary and systemic blood pressure, straining the heart.

♦ Over time, untreated OSA can progress to hypertension, arrhythmias, and heart failure.

♦ Including this complication in education highlights the serious systemic impact of OSA.

♦ Early recognition and treatment with CPAP therapy reduces cardiac risks significantly.

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Answer 6

Correct Answers:

7.5

Rationale :

✍️ Formula: (Desired dose ÷ Available dose) × Volume.

⚫Desired dose = 30 mg;

⚫Available dose = 20 mg per 5 mL.

⚫(30 ÷ 20) × 5 = 1.5 × 5

☑️7.5 mL.

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Answer 7

Correct Answers:

Start discharge planning on the day of admission.

Rationale :

⭐Continuity of care begins immediately upon admission to anticipate client needs.

⭐Early discharge planning allows for coordination of resources, education, and follow-up services.

⭐This prevents delays, reduces readmission risk, and ensures client safety at home.

⭐It also promotes collaboration with the interdisciplinary team for seamless care transitions.

⭐Effective planning empowers clients and families by involving them early in the process.

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Answer 8

Correct Answers:

Decreased bladder tone can cause urinary retention.

Rationale :

📌With aging, bladder muscle tone declines, leading to incomplete emptying.

📌Retained urine creates a favorable environment for bacterial growth, increasing UTI risk.

📌Older adults often have associated conditions like enlarged prostate or neurologic changes that worsen retention.

📌Teaching this helps clients and caregivers monitor for early signs of infection.

📌Preventive strategies such as timed voiding and hydration are essential in this population.

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Answer 9

Correct Answers:

The client's oxygen tanks are stored on their side.

Rationale :

🟠Oxygen tanks must be stored upright and secured to prevent falling or rolling.

🟠Tanks stored on their side risk leaking or explosion if the valve is damaged.

🟠This poses a severe fire hazard, especially in homes with open flames or smoking.

🟠The nurse must intervene immediately to ensure safe storage and handling.

🟠Proper placement prevents accidents and maintains compliance with home safety guidelines.

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Answer 10

Correct Answers:

Request a referral for an occupational therapist.

Rationale :

💎Occupational therapists specialize in helping clients with dementia and ADL difficulties adapt to daily tasks.

💎They provide strategies and assistive devices that promote independence and safety.

💎Early referral maximizes the client’s functioning and quality of life.

💎This also reduces caregiver burden by providing practical interventions at home.

💎Collaboration with OT ensures a multidisciplinary approach to dementia care.

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QLexNursing

1 :
A nurse is caring for a female client who is postoperative and is having difficulty urinating after the removal of an indwelling urinary catheter. Which of the following techniques should the nurse teach the client to use to promote urination?

2 :
A nurse is admitting a client who has been diagnosed with stage 4 cancer and is scheduled for surgery. Which of the following actions should the nurse take?

3 :
A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?

4 :
A nurse is planning to provide discharge teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

5 :
A community health nurse is developing a brochure about obstructive sleep apnea (OSA). Which of the following potential complications of OSA should the nurse include?

6 :
A nurse is preparing to administer phenobarbital 30 mg PO to a client. Available is phenobarbital 20 mg/5 ml. How many ml. should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

7 :
A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client's continuity of care?

8 :
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?

9 :
A nurse is inspecting equipment safety in a client's home. The nurse should identify that which of the following findings requires an intervention?

10 :
A home health nurse is planning care for an older adult client who has dementia and is starting to have difficulty performing activities of daily living (ADLs). Which of the following interventions should the nurse include in the plan of care?

QLexNursing

1 : A nurse is caring for a female client who is postoperative and is having difficulty urinating after the removal of an indwelling urinary catheter. Which of the following techniques should the nurse teach the client to use to promote urination?

2 : A nurse is admitting a client who has been diagnosed with stage 4 cancer and is scheduled for surgery. Which of the following actions should the nurse take?

3 : A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?

4 : A nurse is planning to provide discharge teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

5 : A community health nurse is developing a brochure about obstructive sleep apnea (OSA). Which of the following potential complications of OSA should the nurse include?

6 : A nurse is preparing to administer phenobarbital 30 mg PO to a client. Available is phenobarbital 20 mg/5 ml. How many ml. should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

7 : A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client's continuity of care?

8 : 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?

9 : A nurse is inspecting equipment safety in a client's home. The nurse should identify that which of the following findings requires an intervention?

10 : A home health nurse is planning care for an older adult client who has dementia and is starting to have difficulty performing activities of daily living (ADLs). Which of the following interventions should the nurse include in the plan of care?

1 :
A nurse is caring for a female client who is postoperative and is having difficulty urinating after the removal of an indwelling urinary catheter. Which of the following techniques should the nurse teach the client to use to promote urination?

2 :
A nurse is admitting a client who has been diagnosed with stage 4 cancer and is scheduled for surgery. Which of the following actions should the nurse take?

3 :
A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?

4 :
A nurse is planning to provide discharge teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

5 :
A community health nurse is developing a brochure about obstructive sleep apnea (OSA). Which of the following potential complications of OSA should the nurse include?

6 :
A nurse is preparing to administer phenobarbital 30 mg PO to a client. Available is phenobarbital 20 mg/5 ml. How many ml. should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

7 :
A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client's continuity of care?

8 :
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?

9 :
A nurse is inspecting equipment safety in a client's home. The nurse should identify that which of the following findings requires an intervention?

10 :
A home health nurse is planning care for an older adult client who has dementia and is starting to have difficulty performing activities of daily living (ADLs). Which of the following interventions should the nurse include in the plan of care?