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A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?
- A. Unequal height of the shoulders.
- B. Increased concave curve of the thoracic spine.
- C. Expansion of the upper intercostal spaces.
- D. Increased convex curve of the cervical spine.
Correct Answer: A
Rationale: Unequal shoulder height is a classic sign of scoliosis due to lateral spinal curvature.
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A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the specimen in a clean specimen cup.
- B. Remove 45 mL of urine from the catheter with a syringe.
- C. Clamp the catheter tubing below the needleless port.
- D. Clamp the catheter tubing for 60 min.
Correct Answer: C
Rationale: Clamping below the port ensures a fresh, uncontaminated sample.
A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)
- A. Increased peripheral circulation.
- B. Increased constipation.
- C. Decreased muscle mass.
- D. Decreased cough reflex.
Correct Answer: B,C,D
Rationale: B: Reduced motility causes constipation. C: Sarcopenia reduces muscle mass. D: Weaker cough reflex increases aspiration risk.
A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?
- A. Obtain verbal consent from the client.
- B. Have another nurse co-sign the client's consent.
- C. Check the medical record for the client's signature on a previous consent form.
- D. Witness the client's signature on a consent form.
Correct Answer: D
Rationale: Witnessing the signature ensures informed consent for the procedure.
A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
- A. Encourage your partner to eat three large meals each day.
- B. Opioids will be restricted if your partner develops respiratory distress.
- C. We will use an electric blanket to keep your partner warm.
- D. Assume your partner can hear you, even if they do not respond.
Correct Answer: D
Rationale: Hearing may persist, so speaking provides comfort and connection.
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?
- A. Hypermagnesemia.
- B. Hyperkalemia.
- C. Hyponatremia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, leading to hyponatremia.