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A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Calf swelling
- B. Bradycardia
- C. Clammy skin
- D. Tortuous veins
Correct Answer: A
Rationale: Calf swelling is a common sign of deep-vein thrombosis (DVT) and requires immediate reporting due to risk of complications.
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A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Drink a glass of milk before bedtime.
- B. Watch television in bed.
- C. Take a long walk before bedtime.
- D. Take a 1-hour nap each day.
Correct Answer: A
Rationale: Milk contains tryptophan, which promotes sleepiness.
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. Photograph
- B. Medical diagnosis
- C. Age
- D. Room number
Correct Answer: A
Rationale: A photograph, combined with other identifiers like name and birthdate, ensures positive patient identification.
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?
- A. Hyperkalemia
- B. Hypocalcemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, leading to hyponatremia.
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. Passive range-of-motion exercise
- B. Bowling
- C. Walking
- D. Jogging
Correct Answer: C
Rationale: Walking is a weight-bearing, low-impact exercise that helps improve bone density and is safe for osteoporosis prevention.
A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Ask the client to explain her feelings.
- B. Request that someone from the client's family participate in the care.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
Correct Answer: A
Rationale: Asking about feelings shows empathy and helps address the client’s concerns.