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A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
- A. Obtain blood pressure readings using the client's right arm.
- B. Limit range-of-motion exercises with the affected arm.
- C. Keep both arms below the level of the client's heart.
- D. Use the client's left arm to obtain blood samples.
- E. Elevate the right arm.
- F. Apply compression bandages.
- G. Avoid tight clothing.
Correct Answer: D
Rationale: Using the left arm prevents trauma to the right side, reducing lymphedema risk; BP on the affected arm increases risk.
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A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?
- A. Use a fire extinguisher at the source of the smoke.
- B. Close the doors to the room and to the bathroom.
- C. Activate the fire alarm system.
- D. Assist the client to a nearby common area.
Correct Answer: D
Rationale: Assisting the client to safety is the first priority in a fire emergency per the RACE protocol (Rescue, Alarm, Contain, Extinguish).
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
- A. Assist the client to the restroom 30 min after meals.
- B. Limit the client's physical activity until bowel continence is achieved.
- C. Limit the client's fluid intake to 1500 mL/day.
- D. Instruct the client to limit their intake of high-fiber foods
Correct Answer: A
Rationale: Assisting to the restroom 30 minutes after meals leverages the gastrocolic reflex to promote bowel regularity. Limiting activity, fluids, or fiber would hinder continence efforts.
A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Administer an antiemetic after each meal.
- C. Season foods with spices.
- D. Provide a high-calorie diet.
Correct Answer: D
Rationale: A high-calorie diet addresses malnutrition in AIDS by meeting increased metabolic needs. Large meals may be overwhelming, antiemetics are given before meals if needed, and spices may not be tolerated.
A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Empty the urine into a sterile container labeled with the client identifiers.
- B. Document in the client's electronic medical record that the specimen was sent to the laboratory.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen.
- D. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- E. Clamp the catheter tubing distal to the sampling port for 15 min.
Correct Answer: E,D,C,A,B
Rationale: Order: Clamp (E), wipe port (D), aspirate (C), transfer (A), document (B) ensures sterility and proper procedure.
A nurse is reinforcing teaching with a client who has a prescription for sublingual nitroglycerin for unstable angina. Which of the following instructions should the nurse include in the instructions?
- A. Refill the prescription every 12 months.
- B. Take a second tablet after 5 min for unrelieved chest pain.
- C. Swallow the tablet whole with a glass of water.
- D. Store the medication in the refrigerator.
Correct Answer: B
Rationale: Taking a second dose after 5 minutes for unrelieved pain is standard protocol for nitroglycerin, which is taken sublingually, not swallowed, and stored at room temperature, refilled every 6 months.