Nokea
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Speak with a loud voice while providing the information.
- C. Avoid the use of facial gestures during the instructions.
- D. Determine the client's ability to use a communication board.
Correct Answer: D
Rationale: Assessing for a communication board supports effective teaching for expressive aphasia.
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A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Pull the client's pinna downward and back.
- B. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
- C. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
- D. Request the client remain supine for 10 min following administration.
Correct Answer: C
Rationale: Holding the dropper 1 cm away ensures accurate delivery without contaminating the ear canal.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I will move the cane forward 18 inches.
- C. I will hold the cane on my stronger side.
- D. I should move my stronger leg forward before moving my weaker leg.
Correct Answer: C
Rationale: Holding the cane on the stronger side enhances stability and support for the weaker side.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Dry the wound bed with gauze squares.
- C. Cleanse the wound with cotton balls.
- D. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
Correct Answer: A
Rationale: A 10-mL syringe provides adequate pressure for effective, safe wound irrigation.
A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has rubella
- B. A client who has tuberculosis
- C. A client who is HIV-positive
- D. A client who has had varicella
Correct Answer: D
Rationale: Prior varicella exposure prevents shingles transmission, making this roommate safe.
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.