Nokea
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink two hot cups of coffee each morning.
- B. I take a prescribed opioid pain medication at bedtime.
- C. I love to eat apples and black-eyed peas.
- D. I drink an average of 2,000 milliliters of water daily.
Correct Answer: B
Rationale: Opioids slow bowel motility, increasing constipation risk.
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A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply antiseptic ointment to the tip of my penis.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will clamp the tube when I go for a walk.
Correct Answer: B
Rationale: Keeping the drainage bag below waist level prevents backflow and reduces infection risk.
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Provide the client with finger foods for meals.
- B. Restrict visitors during meals.
- C. Limit snacks between meals.
- D. Provide the client with three large meals each day.
Correct Answer: A
Rationale: Finger foods enhance self-feeding and intake in dementia clients.
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 should wear shoes with smooth soles to help slide my weak leg forward.
- B. I should move my stronger leg forward before moving my weaker leg.
- C. I will move the cane forward 18 inches.
- D. I will hold the cane on my stronger side.
Correct Answer: B
Rationale: Moving the stronger leg first is correct for safe ambulation with a quad cane.
A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Request the client remain supine for 10 min following administration.
- B. Pull the client's pinna downward and back.
- C. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
- D. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
Correct Answer: C
Rationale: Holding the dropper 1 cm from the ear ensures precise administration without contamination.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 50 mg/kg/day = 1250 mg/day; 1250 mg / 4 doses = 312.5 mg/dose; 312.5 mg / (125 mg/5 mL) = 12.5 mL/dose.