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A nurse is performing a wound irrigation for a client who has methicillin-resistant Staphylococcus aureus. When removing personal protective equipment, which of the following pieces should the nurse remove first?
- A. Gloves
- B. Gown
- C. Goggles
- D. Mask
Correct Answer: A
Rationale: Removing gloves first prevents hand contamination when removing other PPE.
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A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I love to eat apples and black-eyed peas.
- B. I drink an average of 2,000 milliliters of water daily.
- C. I take a prescribed opioid pain medication at bedtime.
- D. I drink two hot cups of coffee each morning.
Correct Answer: C
Rationale: Opioids slow bowel motility, increasing constipation risk, unlike fiber-rich foods or hydration.
A nurse is caring for a client who has a terminal illness. The client asks what type of care will be provided as death approaches. Which of the following statements should the nurse make first?
- A. Tell me your expectations about activities related to the end-of-life.
- B. We can talk to the provider about incorporating nonpharmacological pain management in your care.
- C. You can allow your family to visit as often as you wish.
- D. You can provide the name of a spiritual support person we can contact for you.
Correct Answer: A
Rationale: Exploring expectations first ensures care aligns with the client’s needs and preferences.
A nurse is collecting data about cranial nerve function from an adult client. Which of the following images depicts the method the nurse should use to check the function of the hypoglossal cranial nerve (XII)?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: A
Rationale: Image A shows tongue deviation testing, specific to hypoglossal nerve (XII) function.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Inflate the catheter's balloon.
- B. Lower the penis to a 45° angle.
- C. Apply lidocaine gel to the urethra.
- D. Twist the catheter gently.
Correct Answer: D
Rationale: Gentle twisting can navigate urethral obstructions safely without causing trauma.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Use overhead lighting when checking equipment.
- B. Keep the door to the client's room closed.
- C. Provide the client with snug-fitting nightwear.
- D. Administer prescribed diuretics in the evening.
Correct Answer: B
Rationale: Closing the door reduces noise, promoting a sleep-conducive environment.