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A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Inform the client of the adverse effect of diarrhea.
- B. Monitor the client for weight loss.
- C. Advise the client about increased dry mouth.
- D. Check the client for increased hypopigmentation under the patch.
Correct Answer: C
Rationale: Clonidine, an antihypertensive, commonly causes dry mouth as a side effect, and advising the client about this is appropriate for the care plan. Diarrhea, weight loss, and hypopigmentation are not typical effects associated with transdermal clonidine.
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A home health nurse is reinforcing teaching with an older adult client about safety precautions to take in the home. Which of the following instructions should the nurse include?
- A. Place white tape on the edges of stairs.
- B. Place area rugs on wooden floors.
- C. Run wires and cords under carpeting.
- D. Have the furnace inspected every 2 years.
Correct Answer: A
Rationale: White tape on stair edges improves visibility, reducing fall risk in older adults. Rugs and hidden cords are trip hazards, and furnace checks should be annual, not biennial.
A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?
- A. Administer enemas 2 days before the procedure
- B. Do not eat or drink anything except water for 12 hr. before the procedure.
- C. Restrict the diet to clear liquids for 1 to 3 days before the procedure.
- D. Expect the provider to schedule another procedure to remove any polyps
Correct Answer: B
Rationale: A 12-hour fast with only water prepares the colon adequately for a colonoscopy, reflecting standard protocol and client understanding.
A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply heat to my affected ankle to decrease swelling.
- B. I can bear full weight on my affected ankle.
- C. I can dangle my affected ankle from the edge of the bed.
- D. I will wrap my affected ankle with an elastic bandage.
Correct Answer: D
Rationale: Wrapping with an elastic bandage provides compression to reduce swelling in a grade 2 sprain. Heat increases swelling, full weight-bearing is premature, and dangling worsens edema.
A nurse is caring for a client who has a distal radius fracture with a short arm cast applied. Which of the following actions should the nurse take?
- A. Use a hair dryer to blow hot air into the cast to relieve itching.
- B. Perform neurovascular checks of the affected extremity every 2 hr.
- C. Position the fractured arm below the level of the client's heart.
- D. Immobilize the client's fingers using a hand splint.
Correct Answer: B
Rationale: Neurovascular checks every 2 hours assess circulation and nerve function, critical after cast application. Hot air can burn, elevation reduces swelling, and finger immobilization isn't standard unless specified.
A nurse is evaluating a client's acceptance of having a new ileostomy. Which of the following statements by the client indicates acceptance?
- A. I wish my sexual relationship with my partner was like it was before.
- B. I have my partner empty the bag for me, so I don't have to look at it
- C. I look forward to having normal bowel movements again.
- D. I will attend a support group to help me handle difficulties when they occur.
Correct Answer: D
Rationale: Attending a support group shows proactive acceptance and coping with the ileostomy. Other statements reflect denial or avoidance of the new reality.