Nokea
A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Request that someone from the client's family participate in the care.
- B. Ask the client to explain her feelings.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: B
Rationale: Exploring feelings addresses emotional barriers, promoting eventual acceptance of care.
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A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Check the client's skin integrity every 4 hr.
- C. Tie the belt restraint to the side rail of the bed.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown prevents skin irritation and ensures proper fit per safety guidelines.
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. Hypocalcemia
- B. Hypermagnesemia
- C. Hyponatremia
- D. Hyperkalemia
Correct Answer: C
Rationale: Hyponatremia occurs from fluid and sodium loss in vomiting and diarrhea.
A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has tuberculosis
- B. A client who has rubella
- C. A client who has had varicella
- D. A client who is HIV-positive
Correct Answer: C
Rationale: A client with prior varicella is immune to herpes zoster (same virus), minimizing transmission risk.
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. Hold the arms straight when walking.
- C. Keep the crutches at the level of the axillae.
- D. Bear weight on the unaffected leg.
Correct Answer: D
Rationale: The three-point gait involves bearing weight on the unaffected leg while advancing crutches and the affected leg.
A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Take a 1-hour nap each day.
- B. Watch television in bed.
- C. Drink a glass of milk before bedtime.
- D. Take a long walk before bedtime.
Correct Answer: C
Rationale: Milk contains tryptophan, which promotes sleep; other options may disrupt sleep patterns.