A nurse caring for a 60-year-old client with hypertrophy of the prostate gland is required
to remove the retention catheter that was inserted to relieve urinary retention. Which
step should the nurse follow when removing the catheter?
A) Retention catheter should be cut and removed
B) Catheter balloon should be completely deflated
C) Client should be placed in side-lying position
D) Client should be asked to hold his breath during the procedure
B
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A patient with schizophrenia has been taking an antipsychotic drug for several days. The nurse enters the patient's room to administer a dose of haloperidol [Haldol] and finds the patient hav-ing facial spasms
The patient's head is thrust back, and the patient is unable to speak. What will the nurse do? a. Administer the haloperidol as ordered. b. Discuss increasing the haloperidol dose with the provider. c. Request an order to give diphenhydra-mine. d. Request an order to give levodopa.
The nurse is teaching a nursing assistant methods to assist an older client with dementia in performing mouth care. Which instruction should the nurse provide to the assistant?
1. Place a hand over the client's hand and guide the client to perform mouth care. 2. Use sponge swabs to cleanse the gums around the teeth in the front. 3. Brush the teeth quickly for the agitated or irritable client and finish with a mouth rinse. 4. Carefully place two fingers of a gloved hand in the client's mouth to access the back teeth.
The nurse is caring for a client with a lesion in the area of the tibia that is swollen and tender. Which client problem is the highest priority for nursing care?
a. Need for increased calories related to in-creased metabolism b. Pain management related to physical in-jury c. Compromised self-care related to weak-ness d. Safety risk related to skeletal impairment
Lispro is an insulin analogue produced by recombinant DNA technology. Which of the following statements about this form of insulin is NOT true?
1. Optimal time of preprandial injection is 15 minutes. 2. Duration of action is increased when the dose is increased. 3. It is compatible with neutral protamine Hagedorn insulin. 4. It has no pronounced peak.