Nokea
A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?
- A. Do you have any problems taking care of your feet?
- B. Do you go barefoot at home?
- C. Have you noticed any problems with foot swelling?
- D. Have you had a problem with ingrown toenails?
Correct Answer: A
Rationale: This directly assesses ability to perform foot care, critical for diabetes management.
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A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Administering vaginal cream to a client who has a vaginal infection.
- B. Providing postmortem care for a client who has just died.
- C. Suctioning a tracheostomy for a client who has a recent head injury.
- D. Changing a peripheral IV dressing for a client who is postoperative.
Correct Answer: B
Rationale: Postmortem care is within the AP’s scope, involving basic care tasks.
A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)
- A. Increased peripheral circulation.
- B. Increased constipation.
- C. Decreased muscle mass.
- D. Decreased cough reflex.
Correct Answer: B,C,D
Rationale: B: Reduced motility causes constipation. C: Sarcopenia reduces muscle mass. D: Weaker cough reflex increases aspiration risk.
A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?
- A. Administer a sedative medication to the client.
- B. Explain to the client that they cannot leave until the surgeon discharges them.
- C. Have the client sign an against medical advice form.
- D. Tell the client that the surgeon will prescribe restraints if they try to leave.
Correct Answer: C
Rationale: Signing an AMA form documents the client's informed decision to leave against advice.
A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?
- A. He appears anxious about the transfer.
- B. His partner has been visiting.
- C. He is voiding adequately.
- D. He is allergic to sulfa.
Correct Answer: D
Rationale: Allergy information is critical to prevent adverse reactions during care.
A charge nurse is observing a newly licensed nurse who is caring for a group of clients. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?
- A. I will use disinfectant to clean the blood pressure cuff after use on a client.
- B. I will double-bag a client's linens each day.
- C. I will wear sterile gloves when bathing a client who is incontinent.
- D. I will rinse the contaminants from a bedpan with hot water.
Correct Answer: A
Rationale: Disinfecting the cuff reduces cross-contamination, aligning with infection control standards.