Nokea
A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Dangle your legs over the side of the bed.
- B. Use your incentive spirometer.
- C. Increase your intake of protein.
- D. Perform regular isometric exercises.
Correct Answer: A
Rationale: Dangling legs before standing allows gradual adjustment to upright posture, reducing orthostatic hypotension risk.
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A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I can name my sibling as my designee in my durable power of attorney for health care.
- B. I need to create advance directives so that I can donate my organs.
- C. My advance directives can be enforced once my attorney approves them.
- D. A family member will need to witness my signature on my living will.
Correct Answer: A
Rationale: Naming a sibling as a designee is a correct use of a durable power of attorney for health care.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. Family history of osteoporosis
- B. Type 1 diabetes mellitus
- C. Orthostatic hypotension
- D. BMI of 24
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to chronic hyperglycemia affecting blood vessels.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Washing the client's face
- B. Gathering the client's personal belongings
- C. Removing the client's dentures from their mouth
- D. Closing the client's eyes
Correct Answer: C
Rationale: Removing dentures alters appearance unnaturally; they should remain unless otherwise specified.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Cleanse the wound with cotton balls.
- C. Dry the wound bed with gauze squares.
- D. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
Correct Answer: D
Rationale: Holding the syringe 2.5 cm above provides adequate pressure for irrigation without trauma.
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 will move the cane forward 18 inches.
- B. I will hold the cane on my stronger side.
- C. I should wear shoes with smooth soles to help slide my weak leg forward.
- D. I should move my stronger leg forward before moving my weaker leg.
Correct Answer: B
Rationale: Holding the cane on the stronger side provides optimal support and balance for the weaker side.