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A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?
- A. Flex hips and knees when assisting the client to a standing position.
- B. Pivot on the foot farthest from the bed when assisting the client into the chair.
- C. Stand on the client's stronger side when moving the client into the chair.
- D. Raise the bed to waist level before moving the client.
Correct Answer: A
Rationale: Flexing hips and knees uses proper mechanics, reducing injury risk during transfer.
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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 teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Stand with the crutch tips against the feet.
- B. Bear weight on the unaffected leg.
- C. Keep the crutches at the level of the axillae.
- D. Hold the arms straight when walking.
Correct Answer: B
Rationale: Weight on the unaffected leg is key to the three-point gait for stability.
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.
A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?
- A. Clean the hearing aid with isopropyl alcohol.
- B. Turn the hearing aid off for 5 minutes.
- C. Soak the hearing aid in warm water.
- D. Decrease the volume on the hearing aid.
Correct Answer: D
Rationale: Lowering volume addresses feedback, a common cause of whistling.
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.