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A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?
- A. Restrict the number of visitors for clients.
- B. Turn on loud music in client care areas.
- C. Offer the clients many choices regarding care.
- D. Assign different nurses to provide care for clients each day.
Correct Answer: A
Rationale: Restricting visitors minimizes noise and stress, promoting a healing environment.
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A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?
- A. Drink citrus juice with meals.
- B. Train the bladder by voiding every 5 hours.
- C. Apply adult diapers at bedtime.
- D. Perform pelvic-muscle exercises.
Correct Answer: D
Rationale: Pelvic-muscle exercises strengthen the pelvic floor, improving bladder control.
A charge nurse is observing a newly licensed nurse who is caring for a group of clients. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?
- A. I will use disinfectant to clean the blood pressure cuff after use on a client.
- B. I will double-bag a client's linens each day.
- C. I will wear sterile gloves when bathing a client who is incontinent.
- D. I will rinse the contaminants from a bedpan with hot water.
Correct Answer: A
Rationale: Disinfecting the cuff reduces cross-contamination, aligning with infection control standards.
A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?
- A. Apply cornstarch powder to the perineal area.
- B. Turn the client every 4 hours.
- C. Cleanse the perineal area with povidone-iodine solution.
- D. Place a moisture barrier ointment over the perineal area.
Correct Answer: D
Rationale: Moisture barrier ointment protects skin from breakdown due to fecal exposure.
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?
Correct Answer: 660 mL
Rationale: 8 oz milk (240 mL) + 10 oz water (300 mL) + 4 oz gelatin (120 mL) = 660 mL; only liquids are recorded.
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Avoid placing toilet tissue in the bedpan after defecation.
- B. Urinate after the specimen collection.
- C. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- D. Keep the specimen in a warm area.
Correct Answer: A
Rationale: Avoiding toilet tissue prevents contamination, ensuring specimen integrity.