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A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Provide the client with snug-fitting nightwear.
- B. Keep the door to the client's room closed.
- C. Administer prescribed diuretics in the evening.
- D. Use overhead lighting when checking equipment.
Correct Answer: B
Rationale: A closed door minimizes disturbances, promoting sleep.
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A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clean around the stoma with a moisturizing soap.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will cut an opening in the skin barrier that is 1â„2 inch larger than the stoma.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the skin barrier for 30 seconds ensures adhesion, preventing leakage.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I should move my stronger leg forward before moving my weaker leg.
- C. I will move the cane forward 18 inches.
- D. I will hold the cane on my stronger side.
Correct Answer: B
Rationale: Moving the stronger leg first is correct for safe ambulation with a quad cane.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply antiseptic ointment to the tip of my penis.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will clamp the tube when I go for a walk.
Correct Answer: B
Rationale: Keeping the drainage bag below waist level prevents backflow and reduces infection risk.
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. Hyperkalemia
- B. Hypocalcemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, leading to hyponatremia.
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Photograph
- B. Medical diagnosis
- C. Age
- D. Room number
Correct Answer: A
Rationale: A photograph, combined with other identifiers like name and birthdate, ensures positive patient identification.