Nokea
A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?
- A. Hearing acuity intact
- B. Oriented to person only
- C. Full range of motion bilateral lower extremities
- D. Ability to use call light
Correct Answer: B
Rationale: Orientation to person only indicates confusion, increasing injury risk.
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A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?
- A. Drink citrus juice with meals.
- B. Train the bladder by voiding every 5 hr.
- C. Perform pelvic-muscle exercises.
- D. Apply adult diapers at bedtime.
Correct Answer: C
Rationale: Pelvic-muscle exercises (Kegels) strengthen muscles to reduce incontinence.
A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?
- A. Hyperthermia
- B. Urticaria
- C. Dyspnea
- D. Headache
Correct Answer: C
Rationale: Dyspnea is a critical sign of a transfusion reaction, requiring immediate reporting.
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. Make sure four fingers fit between the restraint and the client's body.
- B. Apply the belt restraint over the client's gown.
- C. Check the client's skin integrity every 4 hr.
- D. Tie the belt restraint to the side rail of the bed.
Correct Answer: B
Rationale: Applying over the gown prevents skin irritation and ensures proper fit.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Cleanse the wound with cotton balls.
- B. Use a 10-mL syringe filled with cleansing solution.
- C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
- D. Dry the wound bed with gauze squares.
Correct Answer: C
Rationale: This technique ensures effective irrigation without damaging tissue.
A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?
- A. Determine if the client has a support system.
- B. Schedule a mental health consult for the client.
- C. Provide the client with information about coping strategies.
- D. Encourage the client to attend a support group.
Correct Answer: A
Rationale: Assessing the support system first identifies resources to address ineffective coping.