Nokea
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.
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A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?
- A. Place an identification tag on the outside of the client's shroud.
- B. Ask the assistive personnel to document the client's time of death.
- C. Wear sterile gloves when cleaning the client's body.
- D. Remove the client's dentures and give them to the client's family.
Correct Answer: A
Rationale: An ID tag ensures proper identification for autopsy purposes.
A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?
- A. The client's condition is stable right now.
- B. I will tell him you called.
- C. I cannot confirm or deny that we have a client by that name.
- D. He is here in the hospital, but I cannot tell you anything else.
Correct Answer: C
Rationale: This response protects confidentiality under HIPAA by not disclosing client presence.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Stand with the crutch tips against the feet.
- B. Bear weight on the unaffected leg.
- C. Keep the crutches at the level of the axillae.
- D. Hold the arms straight when walking.
Correct Answer: B
Rationale: Weight on the unaffected leg is key to the three-point gait for stability.
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.
A nurse in a long-term care facility is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?
- A. Apply suction while inserting the catheter.
- B. Apply intermittent suction for up to 30 seconds.
- C. Preoxygenate the client prior to suctioning.
- D. Instruct the client to swallow during catheter insertion.
Correct Answer: C
Rationale: Preoxygenation prevents hypoxia during suctioning, enhancing safety.