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A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. BMI of 24
- B. Type 1 diabetes mellitus
- C. Family history of osteoporosis
- D. Orthostatic hypotension
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to vascular complications.
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A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Secure the restraints with a square knot.
- B. Check the client's range of motion every 6 hr.
- C. Make sure two fingers fit under the restraints.
- D. Request a prescription renewal from the provider every 36 hr.
Correct Answer: C
Rationale: Ensuring two fingers fit prevents excessive tightness, promoting circulation and safety.
A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Increase your intake of protein.
- B. Use your incentive spirometer.
- C. Perform regular isometric exercises.
- D. Dangle your legs over the side of the bed.
Correct Answer: D
Rationale: Dangling legs before standing allows gradual adjustment to upright posture, minimizing orthostatic hypotension risk.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. How will you discuss this decision with your loved ones?
- B. Your quality of life will be compromised if you make this decision.
- C. We should talk about your decision later.
- D. Don't worry. Everything will work out for you.
Correct Answer: A
Rationale: This response supports the client’s autonomy and facilitates discussion about their decision.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Dry the wound bed with gauze squares.
- C. Cleanse the wound with cotton balls.
- D. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
Correct Answer: A
Rationale: A 10-mL syringe provides adequate pressure for effective, safe wound irrigation.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Speak with a loud voice while providing the information.
- C. Avoid the use of facial gestures during the instructions.
- D. Determine the client's ability to use a communication board.
Correct Answer: D
Rationale: Assessing for a communication board supports effective teaching for expressive aphasia.