Nokea
A nurse is assisting in the care of a 72-year-old female client who recently had a stroke and is being monitored for complications. Complete the following sentence by using the lists of options. The client is at risk for developing ___ due to ___.
- A. Deep vein thrombosis (DVT)
- B. Prolonged immobility
- C. Urinary Catheter
- D. constipation
Correct Answer: A,B
Rationale: A: DVT is a risk post-stroke. B: Immobility increases clotting risk.
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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 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. Orthostatic hypotension.
- B. BMI of 24.
- C. Type 1 diabetes mellitus.
- D. Family history of osteoporosis.
Correct Answer: C
Rationale: Type 1 diabetes increases cardiovascular risk due to vascular damage.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Document the refusal in the client's medical record.
- B. Return the medication to the medication cabinet.
- C. Inform the client of the potential consequences of their refusal.
- D. Notify the provider of the client's refusal.
Correct Answer: C
Rationale: Informing about consequences first respects autonomy and may encourage compliance.
A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take?
- A. Keep the client's room well lit.
- B. Encourage the client to abstain from distracting activities.
- C. Ensure that the client's room is kept at a cool temperature.
- D. Play music in the client's room.
Correct Answer: D
Rationale: Music distracts from pain and promotes relaxation, a nonpharmacological approach.
A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?
- A. Place a thick layer of stool on the specimen card.
- B. Urinate prior to collecting the stool specimen.
- C. Discontinue supplements containing vitamin C 24 hours before the test.
- D. Refrain from consuming pork 7 days before the test.
Correct Answer: C
Rationale: Vitamin C can cause false negatives, so discontinuing it ensures accuracy.