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A nurse is caring for a client who is dying. One of the client's family members tells the nurse, 'I need to help. What can I do?' Which of the following actions should the nurse take?
- A. Suggest that the family member contact a grief counselor.
- B. Describe a personal experience with the death of a family member.
- C. Include the family member in providing care for the client.
- D. Ask if they have had prior experience with the death of a family member.
Correct Answer: C
Rationale: Involving the family member in care provides purpose and comfort.
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A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Administering vaginal cream to a client who has a vaginal infection.
- B. Providing postmortem care for a client who has just died.
- C. Suctioning a tracheostomy for a client who has a recent head injury.
- D. Changing a peripheral IV dressing for a client who is postoperative.
Correct Answer: B
Rationale: Postmortem care is within the AP’s scope, involving basic care tasks.
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. Turn the client every 4 hours.
- C. Cleanse the perineal area with povidone-iodine solution.
- D. Place a moisture barrier ointment over the perineal area.
Correct Answer: D
Rationale: Moisture barrier ointment protects skin from breakdown due to fecal exposure.
A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?
- A. Hyperactive bowel sounds are present.
- B. Stomach contents are yellowish green in color.
- C. Aspirated stomach contents' pH measures 6.5.
- D. Residual volume of stomach contents measures 90 mL.
Correct Answer: C
Rationale: A pH of 6.5 suggests possible tube misplacement, requiring immediate reporting.
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Inject air into the ampule prior to drawing the medication into a syringe.
- B. Add 0.5 mL of diluent to the medication.
- C. Use a filter needle to aspirate the medication.
- D. Cleanse the tip of the ampule with an alcohol swab after opening.
Correct Answer: C
Rationale: A filter needle prevents glass particles from entering the syringe, ensuring safety.
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. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Protects skin. D: Monitors for issues. E: Prevents overly tight restraints.