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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.
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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?
- A. Administer a sedative medication to the client.
- B. Have the client sign an against medical advice form.
- C. Tell the client that the surgeon will prescribe restraints if they try to leave.
- D. Explain to the client that they cannot leave until the surgeon discharges them.
Correct Answer: B
Rationale: An AMA form documents the client's informed decision to leave against advice.
A nurse is reviewing the medical record of a client. Click to highlight below the findings that require immediate follow-up.
- A. Neurological: Alert and oriented to person, place, and time; deep tendon reflexes 4+
- B. Musculoskeletal: Generalized weakness with equal bilateral muscle strength and mild leg cramping
- C. Respiratory: Lungs clear
- D. Cardiovascular: Heart rate irregular, Heart rate 95/min
- E. Gastrointestinal: Bowel sounds hyperactive x 4 quadrants
Correct Answer: D
Rationale: An irregular heart rate (D) requires immediate follow-up due to potential arrhythmia risks.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Squeeze the client's finger until a blood drop forms
- B. Prick the side of the client's finger.
- C. Elevate the client's hand above the level of the heart
- D. Cleanse the client's finger with an iodine swab
- E. Using clean gloves
Correct Answer: B, E
Rationale: B: Pricking the side avoids painful areas. E: Clean gloves ensure infection control.
A nurse is reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?
- A. History of dementia
- B. Steady gait
- C. History of gastric reflux
- D. Age of 45
Correct Answer: A
Rationale: Dementia increases confusion and fall risk, predisposing to accidents.
A charge nurse is observing a newly licensed nurse caring for a client group. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?
- A. I will rinse the contaminants from a bedpan with hot water.
- B. I will wear sterile gloves when bathing a client who is incontinent.
- C. I will use disinfectant to clean the blood pressure cuff after use on a client.
- D. I will double-bag a client's linens each day.
Correct Answer: C
Rationale: Disinfecting equipment like a BP cuff prevents cross-contamination between clients.