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A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Request a prescription renewal from the provider every 36 hr.
- B. Check the client's range of motion every 6 hr.
- C. Secure the restraints with a square knot.
- D. Make sure two fingers fit under the restraints.
Correct Answer: D
Rationale: Ensuring two fingers fit prevents excessive tightness and circulation issues.
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A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?
- A. Apply cornstarch powder to the perineal area.
- B. Place a moisture barrier ointment over the perineal area.
- C. Turn the client every 4 hr.
- D. Cleanse the perineal area with povidone-iodine solution.
Correct Answer: B
Rationale: Moisture barrier ointment protects skin from breakdown due to incontinence.
A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?
- A. Discontinue supplements containing vitamin C 24 hr before the test.
- B. Refrain from consuming pork 7 days before the test.
- C. Place a thick layer of stool on the specimen card.
- D. Urinate prior to collecting the stool specimen.
Correct Answer: D
Rationale: Urinating first prevents urine contamination of the stool specimen.
A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
- A. We will use an electric blanket to keep your partner warm.
- B. Encourage your partner to eat three large meals each day.
- C. Assume your partner can hear you, even if they do not respond.
- D. Opioids will be restricted if your partner develops respiratory distress.
Correct Answer: C
Rationale: Assuming hearing persists respects dignity and encourages communication in end-of-life care.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Observe the client's skin integrity every 2 hr.
- B. Use a square knot to secure the client's restraint to the bed.
- C. Ensure that 2 fingers can be placed between the restraint and the client.
- D. Tie the ends of the restraint to the client's bed rail.
- E. Pad bony prominences before applying a restraint.
Correct Answer: A,C,E
Rationale: A: Frequent skin checks prevent injury. C: Two fingers ensure proper fit. E: Padding protects bony areas.
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 rubella
- B. A client who has had varicella
- C. A client who is HIV-positive
- D. A client who has tuberculosis
Correct Answer: B
Rationale: A client with prior varicella is immune to herpes zoster, reducing transmission risk.