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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.
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A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
- A. Provide at least 20 minutes of back massage and gentle efleurage.
- B. Instruct the client to use guided imagery and slow rhythmic breathing.
- C. Place a hot water circulation device, such as an aquathermia pad, on the operative site.
- D. Tune to a television show or easy listening music to provide distraction.
Correct Answer: A
Rationale: Massage complements pain management.
A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?
- A. Offer fruit juice at least twice during both the day and evening shifts.
- B. Encourage the client to eat all of the meals that are sent.
- C. Lower the bed prior to helping the client to move up in bed.
- D. Have the client hold a pillow over the abdomen to cough and deep breathe.
Correct Answer: D
Rationale: Splinting aids breathing.
The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?
- A. Slip-on rubber shower shoes
- B. Tennis shoes with Velcro
- C. Leather-soled loafers
- D. Rubber-soled slippers
Correct Answer: B
Rationale: Velcro shoes provide support and ease of use.
The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails?
- A. Shufling gait.
- B. Urinary incontinence.
- C. Syncope when bending.
- D. Hand tremors.
Correct Answer: A,C,D
Rationale: Mobility and dexterity issues necessitate foot care assistance.
A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?
- A. Skin turgor.
- B. Weight.
- C. Blood pressure.
- D. Lung sounds.
Correct Answer: B
Rationale: Daily weight accurately tracks fluid balance.