Nokea
A client is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates understanding?
- A. I can change my living will whenever I want.
- B. I do not need a living will if I have a durable power of attorney.
- C. My family will make decisions for me if I am unable to.
- D. I need a living will only if I am seriously ill.
Correct Answer: A
Rationale: The correct answer is A because the client understanding that they can change their living will whenever they want shows comprehension of advance directives. Choices B, C, and D are incorrect: B is inaccurate as both documents serve different purposes; C may not always be the case based on the client's wishes and legal documents; D is incorrect because a living will is not only for serious illness but also for end-of-life care decisions.
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A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?
- A. Reposition the client every 4 hours
- B. Use a special mattress for the client
- C. Keep the client on bedrest
- D. Encourage the client to remain in one position
Correct Answer: B
Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.
A healthcare professional is preparing to administer an intramuscular injection to a client. What is the appropriate site for the injection to avoid injury?
- A. Deltoid
- B. Ventrogluteal
- C. Rectus femoris
- D. Dorsogluteal
Correct Answer: B
Rationale: The ventrogluteal site is the preferred site for intramuscular injections to avoid injury to nerves or blood vessels. The deltoid site is commonly used for vaccines but has a higher risk of hitting the radial nerve. The rectus femoris site is not typically recommended for intramuscular injections. The dorsogluteal site is contraindicated due to the proximity to the sciatic nerve and major blood vessels.
A nurse is assessing a client who reports pain at the site of an indwelling urinary catheter. What is the nurse's first action?
- A. Irrigate the catheter with normal saline
- B. Notify the provider
- C. Administer prescribed antibiotics
- D. Assess for signs of infection
Correct Answer: B
Rationale: When a client reports pain at the site of an indwelling urinary catheter, the nurse's first action should be to notify the provider. This is important to ensure timely assessment and intervention by the healthcare provider. Irrigating the catheter with normal saline or administering antibiotics should not be done without provider's orders as it may mask symptoms or lead to inappropriate treatment. Assessing for signs of infection is important but should come after notifying the provider, who can guide further assessment and treatment.
A nurse is teaching about food choices for a client on a low-sodium diet. What food should the nurse recommend?
- A. Canned soup
- B. Fresh fruit
- C. Processed meats
- D. Frozen meals
Correct Answer: B
Rationale: Fresh fruit is a good option for clients on a low-sodium diet as it is naturally low in sodium. Canned soup, processed meats, and frozen meals tend to be high in sodium due to added salt and preservatives, making them unsuitable choices for individuals on a low-sodium diet.
When providing discharge teaching to a client prescribed home oxygen therapy, what information should the nurse include?
- A. Increase the oxygen flow rate during activity
- B. Avoid smoking and open flames near oxygen
- C. Store the oxygen tank in a warm, dry place
- D. Turn off the oxygen when not in use
Correct Answer: B
Rationale: The correct answer is B: 'Avoid smoking and open flames near oxygen.' This information is crucial to prevent fire hazards when using home oxygen therapy. Smoking and open flames near oxygen can lead to serious accidents. Choice A is incorrect because increasing the oxygen flow rate during activity without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored in a well-ventilated area, not necessarily warm and dry. Choice D is incorrect as oxygen should not be turned off and on by the client, as it can affect the therapy's effectiveness and cause safety issues.