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 love to eat apples and black-eyed peas.
- C. I take a prescribed opioid pain medication at bedtime.
- D. I drink an average of 2,000 milliliters of water daily.
Correct Answer: C
Rationale: Opioids slow gastrointestinal motility, increasing the risk of constipation and impaired bowel elimination.
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A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
- A. Obese
- B. Underweight
- C. Ideal body weight
- D. Overweight
Correct Answer: D
Rationale: A BMI of 25-29.9 is classified as overweight; 30+ is obese.
A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will cut an opening in the skin barrier that is 1â„2 inch larger than the stoma.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will clean around the stoma with a moisturizing soap.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the barrier for 30 seconds ensures adhesion, preventing leaks and skin irritation.
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps, placing them in the order of performance.)
- A. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
- B. Open each side flap of the sterile kit individually while pulling to the side.
- C. Prepare a dry work surface above the waist level.
- D. Open the outside cover of the sterile kit and remove the dust cover.
- E. Grasp the outermost flap of the sterile kit while opening away from the body.
Correct Answer: C,D,E,B,A
Rationale: C: Set up surface. D: Open cover. E: Open outermost flap. B: Open side flaps. A: Open innermost flap maintains sterility.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. We should talk about your decision later.
- B. Your quality of life will be compromised if you make this decision.
- C. How will you discuss this decision with your loved ones?
- D. Don't worry. Everything will work out for you.
Correct Answer: C
Rationale: Asking about discussing the decision respects autonomy and encourages communication.
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Check the client's skin integrity every 4 hr.
- C. Tie the belt restraint to the side rail of the bed.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown prevents skin irritation and ensures proper fit per safety guidelines.