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

Exhibits

The nurse is planning care for the client.

Complete the following sentence by using the lists of options.

After providing perineal care and donning sterile gloves, the nurse should first
dropdown
followed by
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

After providing perineal care and donning sterile gloves, the nurse should first lubricate the catheter tip followed by insert the catheter until urine flows.

Rationale:

Lubricating the catheter tip ensures smooth insertion and minimizes discomfort or trauma to the urethra.
Inserting the catheter until urine flows confirms proper placement before advancing slightly more to ensure complete drainage.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Translucent, red tissue Granulation tissue is red or pink due to increased blood supply and is a sign of healing.
B. Soft, yellow tissue This describes slough, which consists of dead tissue and debris that may delay wound healing.
C. Stringy, white tissue This could indicate fibrin or slough, which may require debridement.
D. Thick, black tissue This describes eschar, which is necrotic (dead) tissue and needs removal for proper wound healing.

A. Instruct the client to take small sips of water. B. Ask the client to hyperextend their neck during palpation. C. Inspect the isthmus as the client holds their breath for 5 seconds. D. Assist the client to a supine position prior to the assessment.

Correct Answer is A

Explanation

A. "Instruct the client to take small sips of water."
Having the client take small sips of water helps the nurse observe the thyroid gland as it moves up and down with swallowing, making abnormalities more noticeable.
B. "Ask the client to hyperextend their neck during palpation."
The client should slightly extend (not hyperextend) their neck to relax the muscles and allow for better palpation of the thyroid gland.
C. "Inspect the isthmus as the client holds their breath for 5 seconds."
The thyroid gland is best observed during swallowing, not by holding the breath.
D. "Assist the client to a supine position prior to the assessment."
Thyroid assessment is performed with the client in a sitting or standing position, not lying down.

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Rationale:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document?

Correct Answer is A

Explanation

A nurse is preparing to assess a client's thyroid gland. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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