Nokea
A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
- A. Use a catheter securing device to hold the catheter in place.
- B. Obtain urine from the drainage bag if a urinary specimen is required.
- C. Change the catheter bag every 3 days and as needed.
- D. Position the drainage bag higher than the client's bladder.
Correct Answer: A
Rationale: Securing the catheter prevents movement and reduces infection risk.
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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 reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. I might have headaches due to a decline in my estrogen levels.
- B. I should stop receiving Papanicolaou tests once I reach menopause.
- C. I can expect to have regular periods until I am in menopause.
- D. The best time to perform a breast self-examination is on the first day of my period.
Correct Answer: A
Rationale: Declining estrogen can cause headaches, reflecting perimenopause symptoms.
A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I'm glad to have the opportunity to choose what kind of care I receive while I still can.
- B. I can't change my mind about the care I will receive once I sign my living will.
- C. Once I fill out my living will, there will be a 1-month delay before it is legally binding.
- D. If I want life support, I'll need to sign a separate consent form first.
Correct Answer: A
Rationale: This reflects understanding that advance directives allow care choices while capable.
A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?
- A. Let's talk about what you're thinking.
- B. Is this something you think you can do?
- C. Are you feeling okay?
- D. Do you need more time to absorb this information?
Correct Answer: A
Rationale: Engaging the client about their thoughts addresses distraction and builds rapport.
A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?
- A. I will turn him on his back during seizures.
- B. I will gently restrain him during seizures.
- C. I will loosen his clothing during seizures.
- D. I will insert a washcloth in his mouth during seizures.
Correct Answer: C
Rationale: Loosening clothing ensures comfort and breathing, a safe seizure management step.