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A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Administer prescribed diuretics in the evening.
- B. Use overhead lighting when checking equipment.
- C. Keep the door to the client's room closed.
- D. Provide the client with snug-fitting nightwear.
Correct Answer: C
Rationale: A closed door reduces noise, promoting sleep.
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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. Clamp the catheter tubing below the needleless port.
- C. Clamp the catheter tubing for 60 min.
- D. Remove 45 mL of urine from the catheter with a syringe.
Correct Answer: B
Rationale: Clamping below the port allows fresh urine to collect for an accurate culture.
A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?
- A. A client whose grief response begins following a terminal diagnosis
- B. A client whose grief response is repressed
- C. A client whose grief response is triggered by a secondary loss
- D. A client whose grief response leads to self-destructive behaviors
Correct Answer: D
Rationale: Exaggerated grief involves extreme, self-destructive reactions beyond normal grieving.
A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Episiotomy approximated, 3 cm (1.18 in) in length.
- B. Client instructed on self-care needs.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: A
Rationale: Specific, measurable data like episiotomy status is critical for the health record.
A nurse is assisting with developing a plan of care for a client.
Exhibit 1
Nurses' Notes
2 days ago:
Client admitted to telemetry unit for uncontrolled atrial fibrillation. Admission skin assessment, area of intact, blanchable skin on client's coccyx.
Today, 0900:
Wound on client's coccyx no longer covered with intact skin. Wound involves full-thickness skin loss, shallow depth with no tunneling. New granulation noted. Minimal amount of exudate noted. Client reports wound pain as 5 on a scale of 0 to 10 and is unable to find a comfortable position.
Complete the following sentence by using the lists of options. The nurse understands that which of the following dressing should be added to the plan of care
- A. hydrocolloid
- B. dry gauze
- C. hydrogel
- D. alginate
- E. transparent
Correct Answer: A
Rationale: Hydrocolloid dressings promote healing in full-thickness wounds with minimal exudate.
Nurses'Notes
Day 1:
Client reports to clinic following trip to emergency department (ED) after a fall at home. Reports slipping
on a floor rug and hurting left ankle.
ray report taken in ED shows left lateral malleolus fracture. Removable boot immobilizer in place, using
a cane for assistance in ambulating
Boot immobilizer removed, left ankle with edema +2. Client reports pain as 6 on a scale of 0 to 10.
Client states they were prescribed pain medication by ED provider. Client lives alone.
Reports being "down to 1⁄2 pack of cigarettes, least 3 cups of coffee daily. States their mother was
always breaking something.
Day 3:
Bone Mineral Density DEXA scan -3.8 (-1 or above)
Based on the client's laboratory and diagnostic results, indicate which of the following provider
prescriptions the nurse should expect.
A nurse in a provider's clinic is assisting in the care of an older adult female client.
For each provider prescription click to specify if the provider prescription is expected or unexpected for
the client. There must be at least 1 selection in every row. There does not need to be a selection in every
column.
- A. Physical therapy for muscle-strengthening and balance-training
- B. Calcium 1500 mg po once daily on empty stomach
- C. Vitamin D supplement 2,500 units daily
- D. Home health evaluation of home safety
- E. Increase caffeine intake
- F. Increase daily sun exposure
Correct Answer: A, B, C, D
Rationale: A: Improves strength and reduces fall risk. B, C: Address osteoporosis (DEXA -3.8). D: Ensures safe environment.