Pick Correct Question Explained for Students (Easy Guide)

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Original Question

Pick the correct question and provide rationale for each 3. During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse’s arm. Which of the following actions should the nurse take? A. Wipe the catheter with povidone-iodine and continue the catheter insertion. B. Soak the catheter in chlorhexidine for 15 min and then reattempt insertion. C. Continue with the catheter insertion. D. Obtain a new catheter and reattempt insertion. Rationale: 4. A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following should the nurse include? A. Wake up every 2 hour to urinate during the night. B. Drink citrus juices throughout the day. C. Try to block the urge to urinate until the next scheduled time. D. Limit fluids to no more than 1 L (34 oz) during wake hours. Nurses’ Notes Rationale: 5. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nursing include in the teaching? A. Drink a minimum of 1,00 ml of fluid daily. B. Sit on the toilet for 30 min after eating a meal C. Increase your intake of refined-fiber foods. D. Take a laxative every day to maintain regularity Rationale: 6. A nurse is planning to access the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse used first? A. Inspection B. Auscultation C. Percussion D. Palpation Rationale: 7. A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? A. 3+ Achilles reflex B. Faint pedal pulses C. Feet warm to touch bilaterally D. Capillary refill of <2 sec Rationale: 8. A nurse is caring for a client who has a clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take? A. Wear gloves when changing the client's gown. B. Use alcohol-based sanitzer to cleanse the hands C. Wear a mask when assisting the client with his meal trays. D. Place the client on complete bed rest. Rationale: 9. A nurse is instructing a client about collecting a 24-hr urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication the client understands the procedure? A. The next time I urinate will be the first specimen of the collection. B. I'll make sure to keep the collection bottle in the container of ice they gave me. C. Once the container is half full, I no longer have to add any more urine. D. It's okay if a piece of toilet paper gets in the bottle. The lab people will remove it when they do the test. Rationale: 10 .A nurse is caring for a client who has a pressure injury. (Use the nurse's notes and vital signs from day 1 to help you answer the question.) Nurses' Notes Day 1: Client has a 2 cm (0.79 in) x 3 cm (1.2 in) stage 3 pressure injury on left heel. No drainage or redness noted. Hydrocolloid dressing applied to wound. Vital Signs Day 1: Temperature 37.2°C (99°F) Blood pressure 128/56 mm Hg Heart rate 88/min Respirations 18/min Pulse oximetry 96% on room air Which of the highlighted documentation in the client's medical record below requires further action by the nurse? (Please circle your answer choices.) Day 4: Hydrocolloid dressing removed. Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on left heel. Increased redness at wound borders and purulent drainage noted. Temperature 38.9° C (102° F) BP 118/56 mm Hg Heart rate 102/min Respiratory rate 22/min Pulse oximetry 95% on room air Hct 38% (37% to 47%) Hgb 12 g/dL (12 g/dL to 16 g/dL) WBC 12,000/mm3 (5,000 to 10,000 mm3) During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take?

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