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A nurse is assisting in the care of a client who is postoperative following a hip arthroplasty in the orthopedic unit. The primary health care provider has prescribed pain management and positioning strategies to prevent complications. Complete the following sentence by using the lists of options. The client is at risk for developing ___ due to ___.
- A. Constipation
- B. Opioid use
- C. indigestion
- D. water consumption
Correct Answer: A,B
Rationale: A: Opioids slow bowel motility. B: Common side effect of pain management.
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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.
A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?
- A. Do you have any problems taking care of your feet?
- B. Do you go barefoot at home?
- C. Have you noticed any problems with foot swelling?
- D. Have you had a problem with ingrown toenails?
Correct Answer: A
Rationale: This directly assesses ability to perform foot care, critical for diabetes management.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Prevents skin breakdown. D: Ensures early detection of issues. E: Ensures proper fit and circulation.
A nurse is reviewing the laboratory reports of four clients. Which of the following clients should the nurse expect to have a positive fecal occult blood test?
- A. A client who has ulcerative colitis.
- B. A client who has cholecystitis.
- C. A client who uses laxatives.
- D. A client who has stomatitis.
Correct Answer: A
Rationale: Ulcerative colitis causes colon bleeding, leading to a positive test.
A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, 'I miss being able to go places with my friends.' Which of the following is an appropriate response by the nurse?
- A. We can discuss this when you're not feeling overwhelmed.
- B. Have you tried taking your partner with you when you go out?
- C. Tell me more about your expectations.
- D. I understand how you feel. I've had a relative go through the same thing.
Correct Answer: C
Rationale: Asking about expectations opens dialogue and shows empathy, supporting the partner's needs.