Nokea
A nurse is contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings?
- A. Hypoglycemia
- B. Fluid volume overload
- C. Dermatitis
- D. Kidney stones
Correct Answer: C
Rationale: Dermatitis results from prolonged moisture exposure in incontinence, risking skin breakdown.
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A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?
- A. Let me provide more stimulation in his environment.
- B. Let's wait until tonight to see if he continues this behavior.
- C. I will call the doctor and get the prescription.
- D. I will cover the catheter so he cannot see it.
Correct Answer: C
Rationale: Obtaining a physician's order is required for restraints, used only as a last resort.
A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?
- A. I will turn my mother on her left side during the feeding.
- B. I will position the head of the bed 45 degrees during the feeding.
- C. I will allow the position my mother finds most comfortable during the feeding.
- D. I will elevate the head of the bed 10 degrees during the feeding.
Correct Answer: B
Rationale: Elevating the bed 45 degrees prevents aspiration and aids digestion during feedings.
A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Peripheral edema
- C. Oliguria
- D. Bradycardia
Correct Answer: B
Rationale: Peripheral edema occurs in hypervolemia as excess fluid accumulates in tissues.
A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting?
- A. Dehydration
- B. Urinary frequency
- C. Peripheral edema
- D. Diarrhea
Correct Answer: A
Rationale: Dehydration is a common complication of vomiting due to significant fluid loss.
A nurse is preparing for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed 45°
- B. Massage the client's bony prominences
- C. Provide the client with a high-calorie diet
- D. Reposition the client every 4 hrs
Correct Answer: C
Rationale: A high-calorie diet supports skin integrity and healing, reducing pressure injury risk.