Nokea
A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following questions to determine the client's ability to provide foot self-hygiene?
- A. Do you go barefoot at home?
- B. Have you noticed any problems with foot swelling?
- C. Do you have any problems taking care of your feet?
- D. Have you had a problem with ingrown toenails?
Correct Answer: C
Rationale: Asking about foot care ability directly assesses self-management in diabetes.
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A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?
- A. I will gently restrain him during seizures.
- B. I will loosen his clothing during seizures.
- C. I will insert a washcloth in his mouth during seizures.
- D. I will turn him on his back during seizures.
Correct Answer: B
Rationale: Loosening clothing ensures airway safety and comfort during a seizure.
A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?
- A. Assign different nurses to provide care for clients each day.
- B. Restrict the number of visitors for clients.
- C. Offer the clients many choices regarding care.
- D. Turn on loud music in client care areas.
Correct Answer: B
Rationale: Restricting visitors reduces noise and stress in an acute care setting.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Squeeze the client's finger until a blood drop forms
- B. Prick the side of the client's finger.
- C. Elevate the client's hand above the level of the heart
- D. Cleanse the client's finger with an iodine swab
- E. Using clean gloves
Correct Answer: B, E
Rationale: B: Pricking the side avoids painful areas. E: Clean gloves ensure infection control.
A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
- A. Tell the nurse that permission from the risk manager is required to view the client's record.
- B. Contact facility security to remove the nurse from the unit.
- C. Complete an incident report about the breach of confidentiality.
- D. Remind the nurse that only staff caring for the client may access the client's record.
Correct Answer: D
Rationale: This action reinforces HIPAA compliance without escalating unnecessarily.
A charge nurse is observing a newly licensed nurse caring for a client group. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?
- A. I will rinse the contaminants from a bedpan with hot water.
- B. I will wear sterile gloves when bathing a client who is incontinent.
- C. I will use disinfectant to clean the blood pressure cuff after use on a client.
- D. I will double-bag a client's linens each day.
Correct Answer: C
Rationale: Disinfecting equipment like a BP cuff prevents cross-contamination between clients.