Nokea
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Provide the client with three large meals eachSigma day.
- B. Limit snacks between meals.
- C. Provide the client with finger foods for meals.
- D. Restrict visitors during meals.
Correct Answer: C
Rationale: Finger foods simplify eating for clients with dementia, increasing intake.
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A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Episiotomy approximated, 3 cm (1.18 in) in length.
- B. Client instructed on self-care needs.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: A
Rationale: Specific, measurable data like episiotomy status is critical for the health record.
A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the specimen in a clean specimen cup.
- B. Clamp the catheter tubing below the needleless port.
- C. Clamp the catheter tubing for 60 min.
- D. Remove 45 mL of urine from the catheter with a syringe.
Correct Answer: B
Rationale: Clamping below the port allows fresh urine to collect for an accurate culture.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Apply lidocaine gel to the urethra.
- B. Inflate the catheter's balloon.
- C. Lower the penis to a 45° angle.
- D. Twist the catheter gently.
Correct Answer: C
Rationale: Lowering the penis aligns the urethra, reducing resistance.
A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?
- A. A client whose grief response begins following a terminal diagnosis
- B. A client whose grief response is repressed
- C. A client whose grief response is triggered by a secondary loss
- D. A client whose grief response leads to self-destructive behaviors
Correct Answer: D
Rationale: Exaggerated grief involves extreme, self-destructive reactions beyond normal grieving.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clamp the tube when I go for a walk.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will apply antiseptic ointment to the tip of my penis.
Correct Answer: B
Rationale: Keeping the bag below the waist prevents urine backflow and infection.