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Questions 164

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Question 1 of 5

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate?

Correct Answer: C,D,E

Rationale: Inspecting for skin breakdown (
C), measuring postvoid residuals (
D), and double voiding (E) manage overflow incontinence. Restricting fluids (
A) risks dehydration, and bearing down (
B) may worsen incontinence.

Question 2 of 5

Which teaching instructions should the nurse reinforce to a client with advanced chronic obstructive pulmonary disease?

Correct Answer: B,C,E

Rationale: Pneumococcal vaccine (
B), reporting increased sputum (
C), and incentive spirometry (E) manage COPD. A high-calorie diet, not low-calorie (
A), is needed. Iron (
D) is only indicated for confirmed anemia.

Question 3 of 5

The nurse is caring for a client who is receiving peritoneal dialysis and is reporting chills and abdominal discomfort. The nurse notes rebound tenderness with palpation. Which of the following actions would be a priority for the nurse to take?

Correct Answer: A

Rationale: Chills, discomfort, and rebound tenderness suggest peritonitis, requiring fluid culture (
A). Warming dialysate (
B), pain medication (
C), and positioning (
D) do not address the infection.

Question 4 of 5

The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time?

Correct Answer: B,C,D,E

Rationale: Post-extubation, warmed, humidified oxygen (
B) prevents mucosal drying, ice chips (
C) moisten the mouth, oral sponges (
D) maintain hygiene, and incentive spirometry (E) promotes lung expansion. Oral narcotics (
A) are risky due to potential airway compromise.

Question 5 of 5

A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially?

Correct Answer: B

Rationale: Ensure that the stump is elevated the first day post-op. This priority intervention prevents pressure caused by pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Opioid narcotics are given for severe pain.

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