Nokea
A nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery. Which of the following statements should the nurse make?
- A. You should not worry about it
- B. The surgeon will answer your questions before surgery
- C. It's too late to cancel the surgery
- D. You need to trust the medical team
Correct Answer: B
Rationale: The nurse should encourage the client to express concerns and ensure that the surgeon addresses any questions prior to the procedure.
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A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?
- A. Place the client on their side with their head forward
- B. Call for help
- C. Protect the client's head
- D. Restrain the client
Correct Answer: A
Rationale: Placing the client on their side with their head forward helps maintain an open airway and prevents aspiration.
A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?
- A. Perform palpation before auscultation
- B. Perform percussion before auscultation
- C. Perform palpation after auscultation
- D. Perform inspection after auscultation
Correct Answer: C
Rationale: The correct order for an abdominal assessment is inspection, auscultation, percussion, and then palpation.
A nurse is teaching a group of assistive personnel (AP) about the expected integumentary changes in older adults. Which should the nurse include?
- A. Increase in elasticity
- B. Decrease in pigmentation
- C. Decrease in elasticity
- D. Increase in moisture levels
Correct Answer: C
Rationale: Older adults typically experience a decrease in skin elasticity, which can contribute to various skin-related issues.
A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this finding?
- A. Papule
- B. Vesicle
- C. Macule
- D. Nodule
Correct Answer: C
Rationale: A macule is a nonpalpable lesion smaller than 1 cm in diameter, such as a freckle.
A nurse is reviewing the health history of an older adult who has a hip fracture. The nurse should identify what is a risk factor for developing pressure injuries?
- A. Advanced age
- B. Urinary incontinence
- C. Regular skin assessments
- D. Adequate hydration
Correct Answer: B
Rationale: Urinary incontinence is a risk factor for skin breakdown and pressure injuries.