Nokea
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: B
Rationale: Poorly fitting dentures impair nutrition, a priority health risk requiring immediate attention.
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A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply antiseptic ointment to the tip of my penis.
- B. I will clamp the tube when I go for a walk.
- C. I will keep the drainage bag below the level of my waist.
- D. I will empty my drainage bag once a day.
Correct Answer: C
Rationale: Keeping the bag below waist level prevents urine backflow, reducing infection risk.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Obtain consent from the client.
- B. Request that the provider sign the consent form.
- C. Postpone the procedure until the staff contacts the guardian.
- D. Prepare the client for surgery with implied consent.
Correct Answer: D
Rationale: Implied consent applies in emergencies when the guardian is unavailable, allowing life-saving treatment.
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Limit snacks between meals.
- B. Restrict visitors during meals.
- C. Provide the client with three large meals each day.
- D. Provide the client with finger foods for meals.
Correct Answer: D
Rationale: Finger foods are easier for dementia clients to manage, encouraging self-feeding and intake.
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- B. Keep the specimen in a warm area.
- C. Avoid placing toilet tissue in the bedpan after defecation.
- D. Urinate after the specimen collection.
Correct Answer: C
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen with fibers or chemicals.
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. Bowling
- B. Passive range-of-motion exercise
- C. Jogging
- D. Walking
Correct Answer: D
Rationale: Walking is weight-bearing, promoting bone density safely for osteoporosis prevention.