Nokea
A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?
- A. Contacted the provider to report client findings
- B. Administered medications as prescribed
- C. Reviewed the client's lab results
- D. Discussed the care plan with the family
Correct Answer: B
Rationale: Documenting that medications were administered as prescribed is an example of the implementation of client care.
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A nurse is teaching a client about the correct use of a cane. What should the nurse include?
- A. Ensure the cane has a rubber cap
- B. Hold the cane on the stronger side
- C. Flex the elbow slightly when using the cane
- D. Use a quad cane for increased support
Correct Answer: B
Rationale: The cane should be held on the stronger side to provide support and stability while walking.
A nurse is providing discharge teaching to a client who has a prescription for home oxygen. Which information should the nurse teach?
- A. Use a humidifier with the oxygen
- B. Wear cotton socks when the oxygen is in use
- C. Avoid all types of smoking materials
- D. Use a nasal cannula during meals
Correct Answer: B
Rationale: Wearing cotton socks helps prevent static electricity, which poses a fire risk when using oxygen.
A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?
- A. I understand that I can change my mind anytime
- B. I have a living will that outlines my wishes when I am unable to make a decision
- C. I need to inform my family about my wishes
- D. I don't need to worry about advance directives right now
Correct Answer: B
Rationale: Having a living will indicates the client understands that it outlines their wishes regarding medical treatment when they are unable to make decisions.
A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?
- A. Applesauce
- B. Mashed potatoes
- C. Orange slices
- D. Soft bread
Correct Answer: C
Rationale: Orange slices have membranes that are hard to swallow, which can be problematic for clients on a mechanical soft diet.
A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red and there is warmth along the course of the vein. What should the nurse do?
- A. Continue the infusion
- B. Increase the infusion rate
- C. Discontinue the infusion
- D. Apply a cold compress
Correct Answer: C
Rationale: The symptoms suggest phlebitis. The nurse should discontinue the infusion and may apply a warm compress.