Nokea
A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Request the client remain supine for 10 min following administration.
- B. Pull the client's pinna downward and back.
- C. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
- D. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
Correct Answer: C
Rationale: Holding the dropper 1 cm from the ear ensures precise administration without contamination.
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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. Passive range-of-motion exercise
- B. Bowling
- C. Walking
- D. Jogging
Correct Answer: C
Rationale: Walking is a weight-bearing, low-impact exercise that helps improve bone density and is safe for osteoporosis prevention.
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. Apply lidocaine gel to the urethra.
- B. Twist the catheter gently.
- C. Inflate the catheter's balloon.
- D. Lower the penis to a 45° angle.
Correct Answer: B
Rationale: Gently twisting the catheter may navigate past resistance, often due to the prostatic urethra.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Bear weight on the unaffected leg.
- B. Stand with the crutch tips against the feet.
- C. Hold the arms straight when walking.
- D. Keep the crutches at the level of the axillae.
Correct Answer: A
Rationale: In the three-point gait, weight is borne on the unaffected leg while moving crutches and the affected leg together.
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Calf swelling
- B. Bradycardia
- C. Clammy skin
- D. Tortuous veins
Correct Answer: A
Rationale: Calf swelling is a common sign of deep-vein thrombosis (DVT) and requires immediate reporting due to risk of complications.
The findings in the client's medical record indicate ___ and ___.
- A. Hyperglycemia
- B. Dehydration
Correct Answer: A,B
Rationale: Hyperglycemia: Symptoms of lethargy, thirst, and frequent urination with parenteral nutrition suggest elevated glucose levels. Dehydration: Thirst and frequent urination indicate fluid loss, a risk with parenteral nutrition if not balanced.