Nokea
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. Overweight
- B. Underweight
- C. Ideal body weight
- D. Obese
Correct Answer: A
Rationale: A BMI of 25-29.9 is categorized as 'overweight.' This indicates that the client is above the ideal weight range but has not reached the threshold for obesity.
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A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
- C. Cleanse the wound with cotton balls.
- D. Dry the wound bed with gauze squares.
Correct Answer: B
Rationale: Holding the syringe 2.5 cm above ensures effective irrigation without contamination.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Determine the client's ability to use a communication board
- C. Speak with a loud voice while providing the information.
- D. Avoid the use of facial gestures during the instructions.
Correct Answer: B
Rationale: A communication board aids clients with expressive aphasia in conveying needs, enhancing teaching effectiveness.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Request a prescription renewal from the provider every 36 hr.
- B. Make sure two fingers fit under the restraints.
- C. Check the client's range of motion every 6 hr.
- D. Secure the restraints with a square knot.
Correct Answer: B
Rationale: Two fingers ensure the restraints are secure but not too tight.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Provide the client with snug-fitting nightwear.
- B. Keep the door to the client's room closed.
- C. Administer prescribed diuretics in the evening.
- D. Use overhead lighting when checking equipment.
Correct Answer: B
Rationale: A closed door minimizes disturbances, promoting sleep.
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.