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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 love to eat apples and black-eyed peas.
- B. I drink an average of 2,000 milliliters of water daily.
- C. I take a prescribed opioid pain medication at bedtime.
- D. I drink two hot cups of coffee each morning.
Correct Answer: C
Rationale: Opioids slow bowel motility, increasing constipation risk, unlike fiber-rich foods or hydration.
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A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma bleeds lightly when touched.
- B. The stoma is draining a small amount of liquid stool.
- C. The stoma appears dark in color.
- D. The stoma protrudes slightly from the abdomen.
Correct Answer: C
Rationale: A dark stoma may indicate ischemia, necessitating immediate provider attention.
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Room number
- B. Medical diagnosis
- C. Age
- D. Photograph
Correct Answer: D
Rationale: A photograph provides a unique, visual confirmation of identity for safe medication administration.
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. How will you discuss this decision with your loved ones?
- B. Your quality of life will be compromised if you make this decision.
- C. We should talk about your decision later.
- D. Don't worry. Everything will work out for you.
Correct Answer: A
Rationale: This response supports the client’s autonomy and facilitates discussion about their decision.
A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. There has been too much complaining about these changes.
- B. So you are upset about all of the recent changes on the unit?
- C. Why don't you just file a formal complaint with Human Resources?
- D. Please, try to wait a little longer. Things will get better soon.
Correct Answer: B
Rationale: Acknowledging feelings fosters discussion and support, addressing the AP’s concerns.
A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?
- A. Bowling
- B. Walking
- C. Passive range-of-motion exercise
- D. Jogging
Correct Answer: B
Rationale: Walking, a weight-bearing exercise, strengthens bones, reducing osteoporosis risk safely.