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A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?
- A. Confer with the physical therapist for correct crutch size.
- B. Ask the client to sit down while the crutch length is adjusted.
- C. Assess the client for signs of diminished circulation in the hands.
- D. Proceed with teaching the client how to walk with the crutches.
Correct Answer: D
Rationale: Three-finger gap indicates proper fit.
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The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
- A. Leave the dressing off until consulting with the healthcare provider.
- B. Replace the gauze with a transparent dressing.
- C. Increase the frequency of the dressing changes.
- D. Apply a hydrocolloid gel dressing.
Correct Answer: D
Rationale: Hydrocolloid promotes moist healing.
The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?
- A. Describing a client's illness in the breakroom without mentioning a name.
- B. Discussing health history with the client behind a closed curtain.
- C. Faxing health records to the client's primary healthcare provider.
- D. Sharing a client's discharge needs with other treatment team members.
Correct Answer: A
Rationale: Public discussion risks confidentiality breach.
A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?
- A. Offer comfort that healing can happen at any point in time.
- B. Offer strategies the spouse can use to provide comfort to the client.
- C. Suggest that the spouse go home for a while and get some sleep.
- D. Explain that the staff will strive to keep the client comfortable.
Correct Answer: D
Rationale: Reassurance about care addresses concerns.
The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?
- A. Give the patient 8 ounces (240 mL) of water to drink.
- B. Notify the healthcare provider.
- C. Check the drainage tubing for a kink.
- D. Review the intake and output record.
Correct Answer: C
Rationale: Checking tubing addresses potential obstruction.
A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?
- A. Uses normal saline to irrigate the wound.
- B. Cleans from less soiled to more soiled areas.
- C. Opens a sterile package towards the body.
- D. Places soiled dressing in a plastic bag.
Correct Answer: C
Rationale: Opening towards body risks contamination.