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A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?
- A. Obtain verbal consent from the client.
- B. Have another nurse co-sign the client's consent.
- C. Check the medical record for the client's signature on a previous consent form.
- D. Witness the client's signature on a consent form.
Correct Answer: D
Rationale: Witnessing the signature ensures informed consent for the procedure.
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A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. I might have headaches due to a decline in my estrogen levels.
- B. I should stop receiving Papanicolaou tests once I reach menopause.
- C. I can expect to have regular periods until I am in menopause.
- D. The best time to perform a breast self-examination is on the first day of my period.
Correct Answer: A
Rationale: Declining estrogen can cause headaches, reflecting perimenopause symptoms.
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. Hypermagnesemia.
- B. Hyperkalemia.
- C. Hyponatremia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, leading to hyponatremia.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Protects skin. D: Monitors for issues. E: Prevents overly tight restraints.
A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?
- A. I will turn him on his back during seizures.
- B. I will gently restrain him during seizures.
- C. I will loosen his clothing during seizures.
- D. I will insert a washcloth in his mouth during seizures.
Correct Answer: C
Rationale: Loosening clothing ensures comfort and breathing, a safe seizure management step.
A nurse is assisting in the care of a 72-year-old female client who recently had a stroke and is being monitored for complications. Complete the following sentence by using the lists of options. The client is at risk for developing ___ due to ___.
- A. Deep vein thrombosis (DVT)
- B. Prolonged immobility
- C. Urinary Catheter
- D. constipation
Correct Answer: A,B
Rationale: A: DVT is a risk post-stroke. B: Immobility increases clotting risk.